Inspection on 20/10/05 for Market Street (152)

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Market Street (152) 21/01/08

Market Street (152) 12/05/06

Market Street (152) 18/04/05

Market Street (152) 27/09/04

Market Street (152) 19/04/04

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

CARE HOME ADULTS 18-65 Market Street (152) 152 Market Street East Ham London E6 2PU Lead Inspector Sarah Greaves Unannounced Inspection 20th October 2005 14.00P Market Street (152) DS0000022884.V259245.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 Market Street (152) DS0000022884.V259245.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. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Market Street (152) Address 152 Market Street East Ham London E6 2PU 020 8470 2535 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) Mrs Grace Antwi-Nyame Ms Dorothy Mensah Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th April 2005 Brief Description of the Service: 152 Market Street is a residential home for people with mental health problems and is registered for up to three service users. The home is privately owned and the proprietor works at the establishment. The home is situated in Newham, close to the shopping facilities, amenities and transport links available at High Street North. The home comprises of a single bedroom and a communal lounge on the ground floor, and two bedrooms on the first floor. The home occupies an ordinary domestic property in a residential street. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted in one afternoon. The inspector met both service users and the registered manager. During this inspection, the care plans and risk assessments for service users were read, in addition to policies, procedures and other relevant documents. What the service does well: What has improved since the last inspection? What they could do better: The home must be more vigilant in regard to ensuring that food is stored in the refrigerator in accordance to food hygiene legislation (this is a repeated requirement). The registered manager must also ensure that supervision Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 6 records are available for inspection. A total of eight requirements and two recommendations have been issued in this report. 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. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 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 Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Prospective service users need to be offered a more up-dated version of written information about the home. The current standard of service provision for the present service users demonstrated that the home possesses the capacity to meet the needs of service users. EVIDENCE: The inspector looked at the home’s Statement Of Purpose and Service User’s Guide. It was noted that both of these documents needed to be updated in order to accurately reflect current practices within the home. For example, the Service User’s Guide stated that the home possessed two volunteers, one member of staff was qualified to administer first aid and that all of the staff were qualified cooks. Via discussion with the registered manager, the inspector established that the home does not presently have any volunteer staff, all of the staff possessed a first aid qualification and none of the current staff had presented any evidence to verify their status as qualified cooks. The Service User Guide also contained an inaccurate summary of the home’s complaint procedure, although a correctly presented version was separately available for service users and their representatives. The registered manager was also advised to remove the summary of service users views about the home from the Statement of Purpose and place this information into the Service User’s Guide. The inspector also advised that this literature should clearly state that the advertised ground floor toilet facility is an external toilet. At the time of this inspection, two service users were living at the home and there was one vacancy. The inspector was informed that a previous service user had recently moved on to an independent living unit. During this Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 9 inspection, the inspector read the statutory reviews and Care Planning Approach reports for each service user (review meetings involving the service user, relatives, a representative from the home, allocated social worker, psychiatrist and other professionals such as psychologists). These reports presented a favourable account of how staff at the home supported service users with their individual personal care, rehabilitative, general healthcare and other identified needs. Standards 2,4 and 5 were assessed and met at the previous unannounced inspection visit. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8 and 9 Service users care needs are appropriately identified and planned for via wellwritten care plans and risk assessments. Service users are offered opportunities to contribute to the daily management of the home. EVIDENCE: A requirement was issued in the previous inspection report for the registered manager to ensure that the care plans contained appropriately detailed and comprehensive risk assessments. The inspector read both care plans at this inspection and found these documents to be satisfactorily presented. The risk assessments had been updated and contained sufficient detail. The inspector observed that the various identified needs and planned care for each service user were recorded on one page; the registered manager was advised to space out this information so that each care need was addressed on a separate page. For example, the inspector found via discussion with the registered manager that staff implemented a number of strategies to support a service user with their personal hygiene needs; however, the limited written presentation of the care plan did not fully record staff actions. The inspector looked at the record book for service users meetings. It was noted that these meetings had stopped in July 2005 as the current service users chose not to attend. The minutes of the meetings up until July 2005 Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 11 demonstrated that very positive and constructive issues were discussed, such as advocacy, health promotion, social events and menu planning. The registered manager was recommended to continue these types of discussions with service users through recorded one-to-one meetings. The registered manager had provided service users with details of a local advocacy service; the inspector recommended that the home should obtain more leaflets from the advocacy organisation, as evidence of this could not be produced at the inspection. The inspector observed that a structured approach towards promoting the independence of service users had been advised at Care Planning Approach meetings. The risk assessments addressed this (for example, providing staff supervision to service users for kitchen tasks until appropriate skills, personal safety and confidence were developed); observations by the inspector demonstrated that service users received this level of support in accordance with their individual care plans and risk assessments. During this inspection, the inspector was advised as to why it was necessary for the refrigerator to be kept locked. The inspector recommended that this is discussed in the appropriate Care Planning Approach meeting and recorded within a risk assessment. Standards 7 and 10 were assessed and met at the previous inspection visit. Market Street (152) DS0000022884.V259245.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): 11,14 and 17. Service users are encouraged to avail of opportunities for individual development and to participate in leisure activities of their choice; any issues of poor motivation for social interaction is sensitively discussed with service users and health/social care professionals. Service users received a healthy and enjoyable diet. EVIDENCE: The registered manager informed the inspector of individual challenges in promoting the service users involvement in community and leisure activities; the minutes from the statutory reviews and Care Planning Approach meetings demonstrated that staff had sought advice from external professionals in order to encourage service users to engage in fulfilling activities. The home had organised some restaurant meals but currently service users chose to have a take-away meal instead. Staff provided support to service users for shopping trips and other community based excursions (where applicable); at the time of this inspection, service users were not engaged in any educational or occupational activities. However, the staff were witnessed to be promoting the development of service users independent living skills through activities such as preparing drinks and snacks in the kitchen. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 13 A requirement was issued in the previous inspection report for the registered manager to ensure that service users were provided with a choice of varied food items. The grocery shopping was undertaken on the day of the inspection, which included fresh fruit, snack items and foods that met the cultural and individual preferences of service users. Via discussion with service users, satisfaction with the food service was expressed. Standards 12,13 and 15 were assessed and met at the previous inspection. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, 20 and 21 Service users are competently supported to meet their identified health and personal care needs, including administration of prescribed medications. EVIDENCE: The care plans demonstrated that the personal care needs of service users were identified and addressed. Both service users were registered with General Practitioners although one service user was reluctant to register with a local doctor (this was fully documented in their Care Planning Approach meeting). Staff escorted service users to hospital and other health appointments. The inspector observed that the wider health needs of individuals (for example, dental care, opticians and chiropody) were met. None of the service users were self-medicating at the time of this inspection; any prospective move towards self-medication would be subject to multi-disciplinary discussion and assessment of risks. The inspector checked the storage and administration of medication, which was found to be satisfactory. Prospective service users were informed in the Statement of Purpose that the home does not provide nursing care, although community health services (for example, psychiatric or general district nursing) can be accessed for people if required. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 15 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. Service users are encouraged to make complaints via a clear complaints procedure and access to advocacy. Service users receive care from staff that have received Adult Protection training and are guided by a relevant Adult Protection procedure. EVIDENCE: The service possessed an appropriately written complaints procedure and Adults Protection procedure. The home had not received any complaints since the last inspection and there have not been any complaints sent directly to the CSCI. Staff had received training in Adult Protection. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 16 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, 25, 26, 27, 28 and 30. Standard 29 is not applicable. The home provided a comfortable, clean and suitably homely environment; however, the issues of concern highlighted in this report must be addressed. EVIDENCE: Three requirements relating to the maintenance of the home were issued in the previous inspection report; two of these requirements were found to be satisfactorily met at this inspection and the third requirement was deleted, as it was no longer applicable. The inspector observed that the home was clean, free from any offensive odours and generally well maintained. Potentially harmful cleaning fluids were kept locked up. The inspector noted that the tablecloth in the dining room was torn and needed to be replaced, and a ladder in the rear garden had not been properly attached to a fixture. The toilet seat in the first floor bathroom was scratched and needed to be repaired or replaced; the bathroom was otherwise clean and pleasantly decorated. The inspector was permitted by service users to view both occupied bedrooms; these were satisfactorily decorated and furnished although sparse (this was in accordance to service users choice and other recorded factors). The home is equipped with one communal room and a garden. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 17 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): 33, 34 and 36. Service users benefited from good staffing levels that enabled one-to-one staff support during the daytime and they received care from staff with appropriate training related to service users needs. However, the home must be more rigorous in the record keeping for evidence of staff qualifications and supervision. EVIDENCE: At the time of this inspection, the registered manager staffed the home; a second scheduled member of staff was off sick. The inspector looked at the staffing rota; ordinarily two workers were on duty during the daytime to enable a member of staff to take service users out socially and attend reviews/appointments. Via looking at the staff files and discussion with the registered manager, the inspector found that staff were satisfactorily progressing with National Vocational Qualifications (NVQ) and attending other training (such as managing challenging behaviour). However, not all of the certificates for training were held in staff files (for example, a member of staff who was reported to have completed NVQ level 2 in Care did not have a copy of their certificate to verify this). The inspector had looked at all of the staff files to check recruitment procedures on previous inspections; it was established that there were no newly appointed staff since last year. The registered manager stated that formal one-to-one supervision was being provided at least two-monthly but the most recent copies of supervision were being stored at her home (due to a filing cupboard having been broken but had been replaced at the time of this inspection). The last available supervision Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 18 records for inspection were dated March 2005 and evidenced a good supervision process. Standards 31,32 and 35 were assessed and met at the previous inspection. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41,42 and 43. The home was well managed and operated in the best interests of the service users; however, the home needs to introduce methods to formally seek the views of service users and their representatives. Systems for maintaining the safety of service users were robust apart from the storage of opened, packaged refrigerated food items. EVIDENCE: The registered manager produced evidence of having completed the Registered Managers Award and also has a Diploma in Mental Health studies. The inspector’s observations during the inspection (such as care planning, liaison with external social and health care professionals and interactions with service users) indicated that the management of the service was effective. The home did not evidence any recent quality assurance exercises; the registered manager was advised to undertake quality assurance surveys with service users, their representatives and external professionals involved in the care of service users. The randomly selected sample of policies and procedures seen by the inspector were found to be of a satisfactory quality and documents required by the Care Homes Regulations were appropriately maintained. A Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 20 requirement was issued in the previous inspection report for the home to ensure that all opened, packaged food items were labelled with the date of opening; however, the inspector found a wrapped piece of cheese with no opening or expiry date. Other health and safety practices were assessed at the previous inspection visit and found to be satisfactory. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 21 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 2 X 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 N/A 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 3 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Market Street (152) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 2 3 DS0000022884.V259245.R01.S.doc Version 5.0 Page 22 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 Requirement The registered manager must ensure that the Statement of Purpose is written in accordance to Schedule 1 of the Care Homes Regulations. The registered manager must ensure that the Service User’s Guide is written in accordance with Standard 1(1.2) of the National Minimum Standards. The registered manager must ensure that the torn tablecloth is replaced. The registered manager must ensure that ladders are attached securely when not in use. The registered manager must ensure that the tarnished toilet seat is repaired or replaced. The registered manager must ensure that evidence of regular staff supervision is maintained in the home. The registered manager must ensure that quality assurance systems are developed. The registered manager must ensure that all opened, packaged food items are labelled with the date of opening. DS0000022884.V259245.R01.S.doc Timescale for action 31/01/06 2 YA1 5 31/01/06 3 4 5 6 YA24 YA24 YA24 YA36 16(2g) 13(4c) 23(2c) 18(2) 30/11/05 30/11/05 31/12/05 30/11/05 7 8 YA39 YA42 24(1) 13(4c) 28/02/06 30/11/05 Market Street (152) Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA8 YA9 Good Practice Recommendations The registered manager should offer individual discussion sessions for service users who do not wish to attend group meetings. The registered manager should implement a risk assessment related to the need to keep the refrigerator locked. Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Market Street (152) DS0000022884.V259245.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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