Inspection on 08/11/05 for Unicorn House (16)

This inspection was carried out on 8th November 2005.

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 33 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) 05/03/07

Unicorn House (16) 27/06/06

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

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Unicorn House (16) 16 Campden Road South Croydon Surrey CR2 7EN Lead Inspector James O`Hara Unannounced Inspection 8th November 2005 09:30 Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 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.V258192.R01.S.doc Version 5.0 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.V258192.R01.S.doc Version 5.0 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 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) DS0000025864.V258192.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 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. 18th April 2005 2. 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. 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) DS0000025864.V258192.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. Methods of inspection included formal and informal interviews with some of the home’s staff team, a number of service users, a visiting relative and a friend of two of the service users. The registered manager was not present on the day of the inspection; the team leader supported the inspection process where she could. As the Commission continues to have concerns regarding the very high turnover of staff and the homes heavy reliance on Mauritian students and part time staff the inspection concentrated mainly on staffing standards. Records examined included the home’s Statement of Purpose, staff files and staff training records. Evidence gathered over a number of monitoring visits “Themed Visits” carried out over the last year has also been included in this report. The team leader provided evidence where she could regarding the requirements and recommendations set at the last inspection. The inspector would like to thank the service users, the service users mother, the service users friend, staff and the team leader for their support on the day of the inspection. What the service does well: What has improved since the last inspection? A service user has obtained a new wheelchair and the home now carries out weekly medication stock checks as recommended at the last inspection. The home’s visitor policy has been reviewed and amended to give guidance to people visiting the home late at night and early in the morning so as not to disturb the service users. All but two members of staff attended an Adult Protection training Meeting on the 23rd June 2005 and the service users privacy and dignity was discussed as part of a training session on independence well being and choice on the 16th May. The registered manager informed the Commission that the home had been assessed as meeting the recommendations set by from the London Fire and Emergency Planning Authority on the 24th March. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 6 What they could do better: There had been a history of Unicorn House failing to meet requirements set by the previous regulatory authority the National Care Standards Commission. It was agreed with the trainee manager (now the registered manager Mr Seewoolall) at an announced inspection that took place in June 2004 that the Commission For Social Care Inspection would carry out a number of “Themed Visits” to review outstanding requirements. During these visits outstanding requirements were reviewed and as a result the majority of the requirements had been met. Mr Seewoolall has shown considerable understanding of need for the home to evaluate and improve the facilities and the standard of care for the service users. As a result of the improvements, a number of new systems and formats were developed for the home however these have not been consistently applied and a number requirements made at previous inspections have been restated. There were seven requirements and seven recommendations set at the previous inspection. Four requirements have been met and three are outstanding. As a result of this inspection there are now thirty-three requirements and one recommendation. Many of the requirements set at this inspection relate to the homes Statement of Purpose and staffing records. The Commission continues to have concerns regarding the very high turnover of staff and the homes apparent inability to recruit and retain a staff team that would enhance the lives of the service users. The home continues to recruit students and part time staff from the Mauritian community with no qualifications or previous experience of working in care to support service users, some with mental health needs. These students/trainee staff appear to be offering the majority of care support to the service users. The home’s Statement of Purpose is out of date and misleading especially in relation to the service provided by the staff team and their qualifications. The home no longer employs a Registered Mental Nurse (RMN) or a Registered Nurse Learning Disabilities (RNLD). The qualified psychologist has also left the home. The home’s Statement of Purpose makes no reference to the fact that it employs and trains a large number of students or the arrangement made for their education at the home. The Statement of Purpose’s should also state what staffing arrangements are in place offering service users continuing support when students obtain their qualifications and move on. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 7 Staffing records require to be revised in order to clarify what members of staff are full time, part-time or students. Staff files should include appropriate references, contracts, passports and work permits. Specialist nurses should train staff on the service users medical conditions. An extension was built onto the property however the registered provider failed to inform the local authority planning department thus breaching planning regulations. As a result a requirement has been set in the interest of the health and welfare of service users that the registered provider ensures that the premises is of sound construction. The Proprietor Mr Madhewoo is failing to ensure that monthly visits to Unicorn House by a person not in day-to-day control of the service are carried out. The Commission may consider taking enforcement action in re from the Mauritian community spect of this. During previous inspections it was noted that the registered manager was completing the Registered Managers Award and NVQ level 4 in Care he should inform the Commission if he has completed this qualification. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 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 the following standard(s): 1 and 3. Information included in the homes Statement of Purpose is out of date and misleading. This could result in an inappropriate placement being made to the home. Equally it could result in service users not receiving the service they expected when they first moved to the home. EVIDENCE: The homes Statement of Purpose was examined on the day of the inspection and states that the home employ’s a Registered Mental Nurse (RMN) and a Registered Nurse Learning Disabilities (RNLD). The RMN left the home last year and the deputy manager RNLD is not working at the home. The qualified psychologist has also left the home. The service user’s guide and the statement of purpose should be kept under review (by the registered person Mr Madhewoo) and revised should any changes to the service occur. The Statement of Purpose must accurately reflect the services and facilities offered by the home. The Statement of Purpose makes no reference to the fact that the home now employs and through the training centre, trains a large number of students. It is not clear how the service users benefit from this arrangement. The Statement of Purpose’s must state what staffing arrangements are in place offering service users continuing support while students are learning and what happens when students obtain their qualifications and move on. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 10 In 2004 Mr Madhewoo applied to the Commission for a variation to the home’s registration so that it could offer support to service users with Learning Disabilities and associated Mental Health conditions. During this time the home had appointed a Registered Mental Nurse (RMN). The Commission saw the appointment of this RMN as essential in order that service users with mental health conditions could be in receipt of appropriately services by staff that were supported by a qualified and experienced practitioner. The Commission has serious concerns that at a time of high staff turnover and a core group of inexperienced staff, there are no full time staff qualified and experienced in mental health. The Commission will have to review the admission of any further service users with mental health conditions and may as a result impose a condition on the registration of the home to enforce this. The registered provider must provide evidence of how the mental health needs of the current service users are being met by the current staff team. Mr Madhewoo has obtained further qualifications since the last inspection and as very high number of staff has left the home the section of the Statement of Purpose which shows the staff qualifications is now out of date. The homes Statement of Purpose must be updated to include the relevant qualifications of all staff, the registered provider and manager. It will also need to include the number, relevant qualifications and experience of staff working in the home, indicate under what arrangements staff are employed; the number of full time staff and part time staff, the number of students and the hours they work. The Service Users Guide will need to be reviewed to reflect any changes to the Statement of Purpose. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0. Standards not assessed as met at the last inspection. EVIDENCE: Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 15. The opportunity for service users to receive long-term support in accessing, developing and continuing activities in the community is in danger of not being consistently met as a result of proprietor failing to recruit and retain a permanent staff team. EVIDENCE: The home’s Statement of Purpose states that the home has a philosophy of promoting social inclusion, maximizing the service users potential for maintaining and developing their independence. Weekly service user activity records indicate that service users rely heavily on the Unicorn Workshop and Unicorn Training Institute for activities outside the home. This results in the majority of the service users only ever having contact with Unicorn services and not engaging with the wider community and the opportunities this offers. The high turnover of staff reduces the likelihood that key workers (who are meant to get to know the service user well and advocate for them) will be able Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 13 to support their service users in maintaining and developing their independence. As the staff is predominantly new to the country, their knowledge of local and regional resources is also limited. There are few long term staff left who could assist them to overcome this difficulty. One service user regularly attends Art Therapy at Geoffrey Harris House. None of the service users at the home are employed. The team leader said that she is currently looking for activities for the service users to attend in the Croydon area. At the last inspection it was recommended that the home record all activities attended by service users naming clubs and daycentres attended. The team leader provided evidence (Right Track) where service users activities are recorded. Those records sampled contained very little evidence that the service users had attended any activities other than those provided by Unicorn services. Given that many of the service users have lived in the area for a number of years there is little evidence to suggest that there has been a long-term approach to supporting service users in accessing, developing and continuing activities the local community. The Mr Seewoolall must record evidence of activities attended by service users other than that provided by the Unicorn Workshop and Unicorn Training Institute. The home’s visitor policy has been reviewed and amended as recommended at the last inspection This provides guidance to people visiting the home late at night and early in the morning. This was in order that service users were not disturbed. It is recommended that the new visitors policy indicate the home’s visiting hours and copies should be sent to service users relatives and representatives. The requirement that service users privacy and dignity was to be discussed at the next team meeting was shown to have been met. A further requirement that Mr Seewoolall should discuss with service users what food should be on the menu has not been met and still needs to be addressed.. On the day of the inspection one service user was visited by her mother. Her mother said that her daughter is well settled at the home. A friend of two other service users visited the home. She said that she has known both service users who are brother and sister for many years since she supported them at a home in Ascot. She said that one of the service users had been in a lot of care homes but this is the best he has been in, he is much happier and suited to the home and she has no call to worry about him. She said that the other service user is happy at the home; she also said that the home sometimes arranges for the service users to visit her in Ascot. She also said that staff always makes her feel welcome at the home. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 14 Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 15 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. The health and welfare of service users could be compromised if staff are not trained by specialist nurses on the service users medical conditions. EVIDENCE: A service user has obtained a new wheelchair as recommended at the last inspection. The home now carries out weekly medication stock checks as recommended at the last inspection. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 16 Staffs training records indicate that a specialist diabetic nurse trained all staff in January this year on administering insulin and monitoring blood glucose levels. Since then a substantial number of staff have left the home. The team leader stated that staff had been trained again approximately two months ago but a number of staff have left the home in that short time and new staff have started. She was not able to provide evidence of who had been trained. The registered manager must ensure that all members of staff who administer insulin are trained on administering insulin and monitoring blood glucose levels. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 17 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. The home has an appropriate complaints procedure that provides protection from abuse and allows the service user to feel their views are listened to and acted on. However this will be compromised and service users put at risk if the appropriate recruitment checks are not carried out as required. EVIDENCE: It was recommended at the last inspection that Mr Seewoolall send a copy of the home’s complaints procedures to all of the service users relatives. The team leader was not sure if this recommendation had been followed up. Mr Seewoolall must provide evidence to the Commission that he has sent a copy of the homes complaints procedures to all of the service users’ relatives. During an inspection at the home on the 29th June 2005 evidence was produced that management and all but two members of staff attended an Adult Protection Meeting on the 23rd June 2005. The agenda indicated that the meeting looked at Croydon Councils Protection of Vulnerable Adults Procedure, the homes policies and procedure and staff training. Given that a large number of staff has left the home since the Adult Protection Meeting on the 23rd June 2005 it is required that new staff is trained on the homes and Croydon Councils Protection of Vulnerable Adults Procedure. The registered provider has an office that is situated on the ground floor in the middle of the home. Two administration staff are employed to work in the office. A requirement was set at the last inspection that all members of staff that work in the service user’s home and are in contact with vulnerable adults must have a Criminal Records Bureau Check. The team leader was not able to produce Criminal Records Bureau Checks for these staff. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 18 Mr Madhewoo must write to the Commission indicating the nature of business carried out in his office, the role of the administration staff, their practice regarding contact with service users and access to other areas of the home, and if Criminal Records Bureau Checks have been completed on these staff. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 19 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. The health and safety of service users could be compromised if Mr Madhewoo fails to obtain planning permission and abide by the relevant building regulations. EVIDENCE: Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 20 During the visit to the home on the 18 January 2006 it was noted that an extension had been added to one of the service users’ bedrooms. As a result Croydon Council’s planning department visited the home. It was discovered that Mr Madhewoo had failed to inform the planning department when building this extension. The planning department indicated that the home was in breach of planning regulations and that Mr Madhewoo must submit an application for consent. A letter was received at the Commission’s office from Mr Seewoolall on the 08/11/05 stating that the home has now applied to Croydon Council for retrospective planning permission. Croydon Building Control have made an initial assessment and advised that the home will need to regularise the room. This will be done by means of application and Croydon Building Control is forwarding documents to the home. This is not the first time that Mr Madhewoo has failed to involve the planning authorities in respect of Unicorn Services. Further breeches of this nature will reflect negatively on the fitness of Mr Madhewoo and may result in the Commission taking enforcement proceedings. In the interest of the health and welfare of service users Mr Madhewoo must ensure that building control and regulations are adhered to in any new building activities the premises. As a result of the above Mr Seewoolall was requested to contact the home’s liability insurers to inform them that they were in breach of planning regulations. The liability insurers did not have any concerns as the work had been completed. The Commission will need to have this confirmed in writing. The registered manager must send a copy of the homes liability insurers letter regarding the homes extension to the Commission For Social Care Inspection upon receipt. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 34. Service users cannot be confident that they are supported by competent, qualified, experienced and trained staff or that they will be protected by the home’s recruitment policy and practices. Service users cannot be confident that the staff team who work in the home fully understand their religious, racial, cultural and linguistic backgrounds. EVIDENCE: The Commission continues to have concerns regarding the very high turnover of staff and Mr Madhewoo’s reliance on Mauritian students and part time staff. The home continues to recruit students and part time staff from the Mauritian community with no qualifications or experience of working in care with service users some with mental health needs. Staff rotas indicate that fifteen members of staff have left Unicorn house since January this year and that eleven new members of staff started work at the home of whom six remain. At previous inspections Mr. Madhewoo has expressed that he was aware of the need to recruit a more culturally diverse staff team. A staff team that reflected the cultural needs of the service users, or a staff team that had an Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 22 understanding of how to address their cultural and spiritual needs. To date there is little evidence to suggest that Mr Madhewoo has progressed this. The Commission received a letter on the 8th of August 2005 from Mr Seewoolall stating that Mr. Madhewoo had agreed to freeze employment of any new staff in order to recruit support workers with relevant qualification and experience. This recruitment drive was undertaken through a local job centre. During an inspection at the home on the 18th of August Mr. Madhewoo stated that he did not plan to recruit any more students from Mauritius or any parttime staff and he planned to recruit more full-time members of staff. Mr. Madhewoo agreed that he would write to the Commission indicating his short term and long term plans for employment of staff at the home. Mr Madhewoo wrote to the Commission on the 25th October stating that he had recently advertised the post of support worker at a job centre but was informed that the way he had advertised it could be deemed discriminatory as he stated it was a post for white British staff. Whilst there are sections under the Race Discrimination Act that permits the recruitment of specified staff on the grounds of race or gender, Mr. Madhewoo would have to make an application to the relevant body to be permitted to do this. However the Commission does not consider that only white British people can provide the appropriate levels of support and care for the service users in the home. As previously stated the staff team should have an understanding of how to address and meet the service users cultural and spiritual needs. Mr Madhewoo must ensure that at all times suitably qualified, competent and experienced persons are working in the home in numbers as are appropriate for the health and welfare of the service users. The Statement of Purpose states that unqualified staff are required to undertake a minimum qualification of National Vocational Qualification (NVQ) 2 with others advancing to NVQ 3. However there was no evidence in staff files that current staff had completed any NVQ qualifications. The team leader said that certificates would shortly be sent to the home but she was not sure which members of staff had completed the qualification. Mr Seewoolall must provide evidence to the Commission which staff are undertaking an NVQ and hold a copy of their qualification on their file when completed. At the current inspection eleven of the homes thirteen staff included on the staff rota for November 6th to 13th were Mauritian and the other two staff were from China. The registered provider must make suitable arrangements to ensure that the care home is conducted with due regards to the sex, religious persuasion, Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 23 racial origin, and cultural and linguistic background and disability of service users. So that the Commission can fully assess the impact of the home’s recruitment policy Mr Seewoolall must provide the Commission with a record of all staff that have been employed in the home in the last three years. The records should include the employees names start date, leaving date, employments status i.e. full time/part time/student and their reasons for leaving. If the employee was a student what qualification did they obtain? A letter sent to the Commission by the registered manager on the 02/11/05 stated that eight students worked at the home. At the time of this inspection the team leader stated that one student had resigned. Students employed in the home are entitled under British Immigration regulations to work up to 20 hours during term time and more during half term, though in certain circumstances some students are eligible to work longer hours. The home’s rotas indicate that all but one of the students is working in the home on a full time basis. Mr Seewoolall must ensure that trainee staff work only under the direct supervision of qualified staff and do not undertake intimate personal care tasks. He must also inform the Commission of the numbers of individual students who are employed in the home including the number of hours worked and under what circumstances they are allowed to work more that 20 hours a week.As well as ensuring that trainees make up less than 20 of the total care hours and there is no more than one trainee on duty at any time. The home’s staffing rota must indicate the role of the member of staff, if they are full time or part-time and if they are students and the qualified staff members of staff designated to supervise students. Staff passports were examined. Two members of staff’s passports “ Restriction on Working” indicated that they were only allowed to work in the UK until 28th February 2005. These members of staff are still working in the home. Passports for three members of staff indicated that they had limited leave to work in the UK. Other member of staffs passports did not indicate under what circumstances they were able to work in the UK. The team leader said that three members of staff had returned their passports to the Home Office to be updated. The registered manager must retain current passports for all members of staff employed at the home. Where passports have been removed a record of the reason for their absence must be recorded. The employee’s arrangement Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 24 with the Home Office regarding “Restrictions on Working” and work permits should be kept in the home for inspection. In the event of the agreed Home Office arrangements reaching their expiry date for overseas students working in the home, the proprietor should write and notify the relevant body responsible for their oversight and send a copy to the Commission. One member of staff has recently started work at the home. Their file did not include a Criminal Records Bureau Check or passport and only one reference was available. The registered manager must obtain a Criminal Records Bureau Check, passport and another reference for the new member of staff and notify the Commission when this has been completed. Failure to maintain appropriate employment checks has resulted in notices being issued on a previous occasion. The Commission may decide to undertake further enforcement action in respect of this repeated breech of regulations. In general staff references are returned to Unicorn project by referees however these references are not recorded on the referees company headed paper and do not include a company stamp thus questioning the validity of the reference. Wherever possible the Mr Seewoolall must ensure that all staff references are requested on referees company headed paper and or include a company stamp. Staffing records require a major overhaul as it is difficult to identify which staff are full time or part-time or students. The contract for the new member of staff indicated that he works 20 hours a week part time however the staff rota indicated that he worked full time. The contract does not include the date he started work. One member of staff did not have a contract. The registered manager must ensure that all members of staff have a contract that accurately reflects their employment status on file for inspection. All staff files must include appropriate references, contracts, passports and work permits. Given the fact that the staff turnover is so high is very unlikely that service users have been offered any form of consistent approach to their support and care needs. It is highly unlikely that students who come to the UK to study are able to offer service users the support the need in accessing the local community. The fact that none of the present staff at the home had a NVQ 2 certificate on file and the Statement of Purpose stating that unqualified staff are required to undertake a minimum qualification of NVQ 2 may indicate that once students obtain the qualification they do not remain working at the home. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 25 On the day of the inspection the team leader said that she thought a number of staff were due to receive their NVQ certificates in the near future. The registered manager must ensure that 50 of the staff team excluding managers is qualified to NVQ level 2. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 43. The registered manager continues to show commitment to improving the quality of care in the home however the homes apparent inability to recruit and retain a staff team that would enhance the lives of the service users is seriously undermining his efforts. EVIDENCE: A requirement was set at the last inspection that Mr Madhewoo must make arrangements for a person not in day to day control of the home to visit the home to audit the service and produce a written report. The proprietor has failed to carry out this requirement. Due to this continued failure the Commission may decide to take enforcement action to ensure compliance. During previous inspections it was noted that Mr Seewoolall was completing the Registered Managers Award and NVQ level 4 in Care. Mr Seewoolall must inform the Commission when he has completed the Registered Managers Award and NVQ level 4 in Care. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 27 A requirement set at the last inspection that Mr Seewoolall inform the Commission when the home has been assessed meeting the recommendations set by from the London Fire and Emergency Planning Authority dated 24th March 2005 has now been met. As previously stated the Commission continues to have concerns regarding the very high turnover of staff and the homes reliance on Mauritian students and part time staff. So that the Commission can consider the financial viability of the home the registered provider must • • • Submit a copy of the homes annual accounts certified by an accountant Information as to the financing and financial resources of the care home Details of running costs of the home including the details of salaries and wages paid to individual staff/students. The home must develop an annual development plan for the home, based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 X 1 X X Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 1 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 1 1 1 1 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Unicorn House (16) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X X 2 DS0000025864.V258192.R01.S.doc Version 5.0 Page 29 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 (1) a and b. Requirement Timescale for action 31/01/06 2. YA3 18 (1) c. 3. YA1 4 (1). Statement of Purpose’s must state what staffing arrangements are in place offering service users continuing support while students are learning and what happens when students obtain their qualifications and move on. The registered provider must 14/12/05 provide evidence of how the mental health needs of the current service users are being met by the current staff team. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 6 and 8. Requirement 13 in inspection report 17th and 18th June 2002. The homes Statement of Purpose 31/01/06 must be updated to include the relevant qualifications of all staff, the registered provider and manager. It will also need to include the number, relevant qualifications and experience of staff working in the home, indicate under what arrangements staff are employed; the number of full time staff and part time staff, DS0000025864.V258192.R01.S.doc Version 5.0 Unicorn House (16) Page 30 4. YA1 5 (1). 5. YA17 16 (2). 6. YA20 13 (2) 7. YA22 22 (5) 8. YA23 13 (6) 9. YA1 4 (1) the number of students and the hours they work. Similar requirement included in inspection report 5th and 19th April 2003 Requirement 4. The Service Users Guide will need to be reviewed to reflect any changes to the Statement of Purpose. The registered manager should discuss what food is on the menu with all of the service users. Similar to Requirement 66 in inspection report 17th and 18th June 2002. The registered manager must ensure that all members of staff who administer insulin are trained on administering insulin and monitoring blood glucose levels. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 9. The registered manager must provide evidence to the Commission that he has sent a copy of the homes complaints procedures to all of the service users relatives. A recommendation in the previous report of 18th April 2005. It is required that all new staff is trained on the homes and Croydon Councils Protection of Vulnerable Adults Procedure. The registered provider must write to the Commission indicating the nature of business carried out in his office, the role of the administration staff, their practice regarding contact with service users and access to other areas of the home, and if Criminal Records Bureau Checks have been completed. DS0000025864.V258192.R01.S.doc 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 14/12/05 Unicorn House (16) Version 5.0 Page 31 10. YA24 23 (2) b. 11. YA24 25 (2) e. 12. YA1 18 (1) a. 13. YA33 12 (4) b. 14. YA34 17 (2) and (4) Requirement 10 in inspection report 17th and 18th June 2002. In the interest of the health and welfare of service users the registered provider must ensure that building control and regulations are adhered to in any new developments in the premises. Similar to Requirement 87 in inspection report 17th and 18th June 2002. The registered manager must send a copy of the homes liability insurers letter regarding the homes extension to the Commission For Social Care Inspection upon receipt. The registered manager must provide evidence to the Commission which staff are undertaking an NVQ and hold a copy of their qualification on their file when completed. Recommendation 8 in inspection report 17th and 18th June 2002. The registered provider must make suitable arrangements to ensure that the care home is conducted with due regards to the sex, religious persuasion, racial origin, and cultural and linguistic background and disability of service users. Similar to Requirements 43 and 44 in inspection report 17th and 18th June 2002. The registered manager must provide the Commission with a record of all staff that has been employed in the home in the last three years. The records should include the employees name start date, leaving date, employments status i.e. full time/part time/student and their DS0000025864.V258192.R01.S.doc 08/11/05 14/12/05 14/12/05 08/11/05 08/11/05 Unicorn House (16) Version 5.0 Page 32 15. YA33 18 (1) 12 (1) 16. YA33 18 (1) a. 17. YA33 12 (1) 18 (1) 18. YA33 18 (1) a. 19. YA34 19 (1) b. reasons for leaving. If the employee was a student what qualification did they obtain? Similar requirement included in inspection report 5th and 19th April 2003. Requirement 58. Similar to Requirement 30 in inspection report 17th and 18th June 2002. The registered manager must inform the Commission of individual students who are employed in the home including the number of hours worked and under what circumstances they are allowed to work more that 20 hours a week. The registered manager must ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of the service users. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 58. Similar to Requirement 30 in inspection report 17th and 18th June 2002. The registered manager must ensure that trainee staff work only under the direct supervision of qualified staff and do not undertake intimate personal care tasks. The registered manager must ensure that trainees make up less than 20 of the total care hours and there is no more than one trainee on duty at any time. The registered manager must retain current passports for all members of staff employed at the home. Where passports have been removed a record of the reason for their absence must be recorded. The DS0000025864.V258192.R01.S.doc 08/11/05 08/11/05 08/11/05 08/11/05 08/11/05 Unicorn House (16) Version 5.0 Page 33 20. YA34 19 (1) b. 21. YA34 19 (1) b. 22. YA34 19 (1) b. 23. YA34 17 (2). 24. YA34 19 (1) b. employee’s arrangement with the Home Office regarding “Restrictions on Working” and work permits should be kept in the home for inspection. In the event of the agreed Home Office arrangements reaching their expiry date for overseas students working in the home, the proprietor should write and notify the relevant body responsible for their oversight and send a copy to the Commission. The registered manager must obtain a Criminal Records Bureau Check, passport and another reference for the new member of staff and notify the Commission when this has been completed. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 44. Similar to Requirement 10 in inspection report 17th and 18th June 2002. Wherever possible the registered manager must ensure that all staff references are requested on referees company headed paper and or include a company stamp Similar to Requirement 29 in inspection report 17th and 18th June 2002. The registered manager must ensure that all members of staff have a contract that accurately reflects their employment status on file for inspection. All staff files must include appropriate references, contracts, passports and work permits. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 43 and 46. Similar to Requirement 28 in inspection report 17th and DS0000025864.V258192.R01.S.doc 08/11/05 08/11/05 08/11/05 08/11/05 08/11/05 Unicorn House (16) Version 5.0 Page 34 18th June 2002. 25. YA34. 18 (1) a. The registered manager must 08/11/05 ensure that 50 of the staff team excluding managers is qualified to NVQ level 2. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 41. Recommendation 8 in inspection report 17th and 18th June 2002. The registered manager must 31/01/06 inform the Commission if he has completed the Registered Managers Award and NVQ level 4 in Care and if not when he will complete. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 51. 31/01/06 So that the Commission can consider the financial viability of the home the registered provider must • Submit a copy of the homes annual accounts certified by an accountant Information as to the financing and financial resources of the care home 26. YA37. 9 (2) b (i) 27. YA43 25(2) a,d and(3) • 28. YA13. 16 (2) m. Details of running costs of the home including the details of salaries and wages paid to individual staff/students. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 60. The registered manager must record evidence of activities attended by service users other than that provided by the Unicorn Workshop and Unicorn Training Institute. DS0000025864.V258192.R01.S.doc • 31/01/06 Unicorn House (16) Version 5.0 Page 35 29. YA35 18 (1) b. 30. YA34 19 (1) b. 31. YA43 26 (1) 32. YA39 24 (1) a and b 33. YA33 18 (1) b. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 24 and 25. 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. Requirement not met from previous inspection 18th April 2005. 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. Requirement not met from previous inspection 18th April 2005. Similar to Requirement 10 in inspection report 17th and 18th June 2002. The registered provider must make arrangements for visits under regulation 26. Requirement not met from previous inspection 18th April 2005. The home must develop an annual development plan for the home, based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. Similar requirement included in inspection report 5th and 19th April 2003. Requirement 56. The homes staffing rota must indicate the role of the member of staff, if they are full time or part-time. If they are students the qualified staff members of staff designated to supervise them. DS0000025864.V258192.R01.S.doc 31/07/05 31/07/05 31/07/05 31/01/06 08/11/05 Unicorn House (16) Version 5.0 Page 36 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 YA15 Good Practice Recommendations It is recommended that the new visitors policy indicate the home’s visiting hours and copies should be sent to service users relatives and representatives. Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 37 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Unicorn House (16) DS0000025864.V258192.R01.S.doc Version 5.0 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!