Inspection on 29/09/05 for Sisserou

This inspection was carried out on 29th September 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sisserou 28/08/07

Sisserou 14/08/06

Sisserou 01/04/05

Sisserou 20/07/04

Sisserou 19/04/04

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 Sisserou Sisserou 196 South Esk Road Forest Gate London E7 8HD Lead Inspector Seka Graovac Unannounced Inspection 29th September 2005 10:55 Sisserou DS0000030770.V255069.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 Sisserou DS0000030770.V255069.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. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sisserou Address Sisserou 196 South Esk Road Forest Gate London E7 8HD 020 8586 7812 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) Sisserou Mrs Theresa John Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one (1) named service user over the age of 65 years. 1st April 2005 Date of last inspection Brief Description of the Service: The Sisserou is a small residential care home for three people with learning disabilities. It is situated in a quiet residential street but close to public transport and other amenities in Forest Gate area of East London. There is a garden at the back of the house and unrestricted parking is available on the street. The home’s statement of purpose lists a range of care and support needs that the home aims to meet. It is stated that that the Sisserou is suitable for people who have failed to develop in larger residential settings, have low self-esteem and confidence and have difficulties in forming and sustaining relationships. The home is owned and managed by Mrs Theresa John. She also owns and manages another home for three people with mental disorder that is located next door to the Sisserou. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The main purpose of this unannounced inspection was to follow up on the requirements that had been made at the previous unannounced inspection in April 2005. Apart from one, all key standards were inspected at the previous visit and some of them were re-assessed on this occasion. The inspection lasted approximately one hour and a half. Only one service user and the Registered Person (Proprietor-Manager) were on the premises and the inspector spoke to both of them. There have been no new admissions to the service since the previous inspection. The inspector also conducted a partial tour of the home and examined the following records: terms and conditions of placements, healthcare related records, medication records, complaints, visitors book, staff roster, service users’ meetings minutes and fire-safety records. What the service does well: What has improved since the last inspection? What they could do better: The only service user in the building at the time of the inspection was looked after by the manager. The home needs to review this practice and the staffing levels. The business plan for the home was not available for inspection. The Registered Person must ensure that there is an annual business and development plan for the home, based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 6 The monitoring records were not available either. The Registered Person must ensure that there is a continuous self-monitoring and involving service users in the process. The inspector was informed that the service users’ meetings were held twice a year and the minutes were available for inspection. The inspector recommended that these meetings were held on a more regular basis. The management conducted a satisfaction survey that included relatives, social and health care professionals, but the report of findings was not available at the time of the inspection. The Registered Person must ensure that the results of service users’ and their representatives’ satisfaction surveys are published and made available to them and other interested parties, including the Commission. The inspector also recommended that the home keeps a protection issues log. 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. Sisserou DS0000030770.V255069.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 Sisserou DS0000030770.V255069.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): 5. The service users were protected by individual written statements of terms and conditions signed by all relevant parties. EVIDENCE: The inspector viewed the written statements of terms and conditions for the service provision for all service users that were signed by all relevant parties. There were no new admissions to the home since the previous inspection. The service users’ assessments were examined at the previous inspection. The Registered Person stated that the assessment format has been reviewed since then. This standard was not re-assessed on this occasion. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All key-standards regarding Individual Needs and Choices were assessed as met at the previous inspection and were not re-assessed on this occasion. EVIDENCE: None needed. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13. The service users led active lives. EVIDENCE: All key-standards were assessed at the previous inspection as met. Standard 13 was the only one that was re-assessed on this occasion. On the day of the inspection, only one service user was at home. She told the inspector that she was also planning to go out to the local shop and buy a can of coke. The inspector was informed that one service user was attending needlework classes at the local college, escorted by a staff member. The other service user was attending a health appointment, also escorted by another staff member. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20. Service users’ physical and emotional health needs were met. This included the appropriate administration of medication as prescribed. EVIDENCE: All key-standards were assessed at the previous inspection. Standards 19 and 20 were re-assessed on this occasion. The inspector examined health records for all three service users. The records were comprehensive and included referrals to a wide range of health professionals. They indicated that the service users’ health was regularly monitored. The appropriate referrals were made when it was needed and guidance issued by other professionals were followed. The inspector also examined medication administration records and found them to be satisfactory. All the medicines (including the refrigerated ones) were appropriately securely stored. The inspector also saw the home’s contract with the local pharmacist and record of related training held. British National Formulary was available in the home, providing essential information about the medicines used by the service users in the home. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home implemented the appropriate policies and procedures regarding dealing with complaints and protection issues. EVIDENCE: Both standards related to concerns, complaints and protection were assessed at the previous inspection as met. Both standards were re-assessed on this occasion. The inspector examined the complaints-log that indicated that the home appropriately dealt with two complaints since the previous inspection. The Commission for Social Care Inspection was notified about a protection issue that the home also appropriately dealt with via Local Authority Protection of Vulnerable Adults procedures. The inspector recommended that a protection issues log is created by the home. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The service users lived in a comfortable, safe and clean environment. EVIDENCE: Both key-standards regarding the environment were assessed as met at the previous inspection. Both were re-assessed on this occasion. The inspector saw all the communal areas in the home and found them to be safe, clean and well maintained. The service user also showed her bedroom to the inspector and this was satisfactory too. The service user told the inspector that she liked her room. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33. The only service user in the building at the time of the inspection was looked after by the manager. The home needs to review this practice. EVIDENCE: At the time of the inspection, only the Registered Manager was in the building and she was also responsible for managing another care home next door to Sisserou. There was one service user in the building and she was clearly expressing her wish to go out shopping. While the manager and the inspector were in the upstairs office with the door being left open, the service user was at the bottom of stairs looking at them longingly and occasionally calling: “Come on. Take me”. The other two staff who were on duty were out with the service users. The manager stated that one of them would be returning to the service shortly. The inspector was also informed that the home next door had one staff member and one service user in the building at the time. The inspector recommended that the staffing levels are reviewed and the strategy is put in place to address the situations like the one described above. This was further discussed at the inspection. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The Registered Person must monitor the home’s service provision and develop a business-development plan that is underpinned by the stakeholders views. EVIDENCE: The Registered Manager is also a Registered Provider for this and the next door home called Meafin Lodge. She is experienced in care management and has an Advanced Management in Care Qualification. The inspector was also informed that the Registered Person was working towards NVQ (National Vocational Qualification) in Management and that she obtained a degree in Psychology a year before this inspection. The business plan for the home was not available for inspection. The Registered Person stated that she was working on it at her own private home. The Registered Person must ensure that there is an annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 16 The monitoring records were not available either. The Registered Person must ensure that there is a continuous self-monitoring and involving service users. The inspector was informed that the service users’ meetings were held twice a year and the minutes were available for inspection. The inspector recommended that these meetings were held on a more regular basis. The management conducted a satisfaction survey that included relatives, social and health care professionals, but the report of findings was not available at the time of the inspection. The Registered Person must ensure that the results of service users’ and their representatives’ satisfaction surveys are published and made available to them and other interested parties, including the Commission. The inspector examined the home’ s fire-safety log and found out that the firealarm tests were conducted on a weekly basis as required. The last recorded fire-drill happened in April 2005. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standa rd No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score 3 3 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 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sisserou Score X 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 X 2 X 3 3 2 DS0000030770.V255069.R01.S.doc Version 5.0 Page 18 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 YA39 Regulation 24 Requirement The Registered Person must ensure that there is a continuous self-monitoring and involving service users and that the related records are available for inspection. The Registered Person must ensure that the results of service users’ and their representatives’ satisfaction surveys are published and made available to them and other interested parties, including the Commission. The Registered Person must ensure that there is an annual development and business plan for the home, based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users. Timescale for action 30/11/05 2 YA39 24 31/12/05 3 YA43 25 31/12/05 Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA23 YA32 YA39 Good Practice Recommendations The inspector recommended that the home creates a protection-log. The inspector recommended that the staffing levels are reviewed and the strategy is put in place to address the situations like the one described above. The inspector recommended that service users’ meetings were held on a more regular basis. Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 20 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 Sisserou DS0000030770.V255069.R01.S.doc Version 5.0 Page 21 - 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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