Inspection on 25/05/05 for Jewish Care

This inspection was carried out on 25th May 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Jewish Care 01/11/07

Jewish Care 24/07/06

Jewish Care 21/12/05

Jewish Care 30/09/04

Jewish Care 20/05/04

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

CARE HOME ADULTS 18-65 Jewish Care 7B Mapesbury Road London NW2 4HX Lead Inspector Andreas Schwarz Unannounced 25 May 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Jewish Care Address 7B Mapesbury Road~ London NW2 4HX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8459 2569 020 8459 4855 Jewish Care Mr Padraic Garrett Care Home 25 Category(ies) of Mental Disorder, exluding learning disability or registration, with number dementia (MD) - 25 of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) - 14 Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Mental disorder, excluding learning disability or dementia (25), Mental Disorder, excluding learning disability or dementia - over 65 years of age (14) Date of last inspection 30/09/04 Brief Description of the Service: 7b Mapesbury Road is a purpose built house with a very large well-main tained garden at the rear of the property. It is in a quiet residential road, but within walking distance of good public transport links and close to Kilburn High Road shopping centre. The home is run by Jewish Care and provides accommodation for 25 adults with mental health problems. The age of the service user ranges from 50 to 86 years. A registration variation has been applied for in order to accommodate those service users over the age of 65. All service users have good-sized single rooms and there are also five flats with ensuite facilities. There is a large dining/lounge area on the ground floor that opens out to a beautifully maintained garden and two further lounges on the first and second floor, one of which accommodates service users who smoke. There is off-street parking at the front of the property. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place in May 2005. The manager and deputy manager was available throughout this inspection. The inspector spoke to staff, residents and sampled documents to support his findings at this inspection. The manager was in his last week of employment and the inspector was informed that the Deputy Manager would act up until a permanent replacement has been found. The inspector would like to take the opportunity thanking manager, staff and residents for being so welcoming throughout this inspection. What the service does well: What has improved since the last inspection? The home has complied with all requirements made in the previous inspection report. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 6 What they could do better: 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. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 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 standard(s) 2 Residents’ needs are assessed appropriately and service users are encouraged to participate in the assessment process. EVIDENCE: The inspector viewed the homes admission procedure, which was judged of being of good standard. Residents informed the inspector of being happy with the admission process and how the home involves the multi disciplinary team. The homes assessment forms are thorough and of high standard and relevant information are included in the care planning process. Residents are assessed by the manager and offered a trial stay before committing to moving into the home. Previous requirements have been complied with. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 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 standard(s) 6; 9 Residents’ are involved in the care planning processes and are encouraged to participate in review meetings. Residents’ risks have been assessed to high standards and independence will be maintained as long as there is an acceptable risk. EVIDENCE: The inspector sampled five care plans, all of them were found to be in order and it was evident that the home reviews care plans regularly. Residents are involved in these processes and the home is inviting family and clinicians to attend one care plan review per year. Care plans are provided in English and the inspector discussed with the manager providing the care plans in different languages, i.e. one resident speaks Spanish and Hebrew. The home has clear risk assessments in place. Risk assessments can be accessed in resident files or in a separate file were the home files all risk assessments. The home has a wide range of risk assessments in place, ranging from relationship/sexuality, missing person, self-harm, etc. Risk assessments are reviewed regularly. The inspector recommended including residents in this process. The home has a robust missing persons procedure in place. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 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 standard(s) 12; 13; 14; 17 Residents are supported appropriately in taking part in activities. Residents can access the community whenever they want, depending if the person is safe and prior to having a risk assessment developed. The home provides in-house activities, which provides appropriate stimuli to residents. The home provides kosher food to residents. All residents are encouraged to participate in the menu planning process. EVIDENCE: The home offers a wide variety of activities for residents ranging from gardening, card games, relaxation, etc. An activity co-ordinator is employed on a part time basis, who is planning sessions with and for residents and organises Jewish festivals, such Hanukah, Passover, etc. The inspector observed residents attending activities during this inspection and positive feedback was received about the group sessions. The manager informed the inspector, that some residents have small jobs around the home, i.e. gardening, picking up litter, load the dishwasher, etc. Residents confirmed this and informed the inspector that they receive a small payment from the home after they have successfully completed the task. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 11 Residents informed the inspector of having good relationships with neighbours. The inspector observed residents leaving the home on their own to do some shopping at the local high street. Residents are free to go to the cinema, pub, café provided it is safe for them to go and risk assessments has been put in place. The home is run by Jewish Care and follows the Jewish way of life; this includes celebration of religious festivals, kosher food, visits of the local synagogue, etc. Residents can be registered with electoral register and vote if they wish to do so. One resident confirmed this to the inspector. Residents are offered a wide range of activities and the inspector observed residents attending in-house groups during this inspection. There are TV’s, music systems, and a piano available in the communal areas. Two residents invited the inspector to see their room, which were nicely decorated and all rooms had a TV, music system, books, etc. Residents confirmed going to Bournemouth this summer for an annual holiday, which has been chosen within residents meetings at the beginning of this year. The activity cocoordinator is a qualified music therapist; she provides different sessions for residents in the home. The inspector assessed the homes menu, which provides a choice of two main courses. This is discussed with residents in the morning and allows making a choice. The inspector did not sample a meal during this inspection, but observed the lunch. The meal was judged as being well presented and residents confirmed that they like the food. The home has fortnightly “chefmeetings” allowing residents to choose a menu and raise complains about the food provided with the chef. The home is providing kosher food following The London Beth Din Kashrut Divisions rules. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19; 20 Residents’ physical and emotional health needs have been well attended to and good monitoring processes are in place. Medication for residents is administered appropriately. Policies and procedures as well as risk assessments are in place to keep residents safe from incorrect administration. EVIDENCE: The home has very good relationships with the local mental health team and records show that residents care plan reviews are attended regularly by the community psychiatric nurse (CPN) and consultant psychiatrist. Additionally the CPN visits the home frequently to assist residents and provides clinical support. Since increasing the residents’ age to over 65, the home started to build relationships with Brent Older People Team and records showed that residents have received help in pressure care and other age related illnesses or conditions. All residents are registered with their own GP and clinical appointments can be attended to in the privacy of residents’ rooms. Residents’ health is well monitored and staff support service users in attending any health related appointments if needed. The medication cupboard is located in the office, one designated member of staff is re-ordering, checking and receiving medication delivered to the home. There is a separate cupboard for the storage of controlled drugs and the correct procedures are in place for the administration of these. Staff receives a Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 13 training day within the induction process. One resident is self-administering medication, this has been separately risk assessed by the manager. MAR sheets were found to be of good standards and no gaps were found. There is a signatory list available in the homes’ medication file. The pharmacist is visiting the home every three months to assess the homes medication procedures. Allergy information was not documented on the MAR sheets, this was pointed out to the manager and is required. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The residents’ living at the home can express their concerns and have different opportunities to complain. EVIDENCE: The homes’ complaint book is made readily available in the dining room and manager reviews the book on a weekly basis. The complaints policy is displayed in the hallway of the home and residents confirmed to know about the policy and who to complain to. The complaints policy does not include the CSCI new title, which is required. There is a separate record for written and verbal complaints, these are followed by the manager and the outcome are recorded. The registered provider checks complaints on each monthly visit and records of these visits have been forwarded to the inspector for assessment. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24; 30 Residents live in a nicely decorated and homely environment and get the opportunity to voice any changes in meetings made available. The home is clean and was free of any offensive odours. EVIDENCE: 7B Mapesbury Road is large three storeys building located in Kilburn. Considering it is such a large property it has a homely feel to it and pictures as well as ornaments are displayed throughout the building. There is enough communal space available. There is a big lounge/ dinning room on the groundfloor, a smoking room on the first floor and a quiet lounge on the second floor. Accommodation is provided on all floors and there are five ensuite flats available on the third floor. Four rooms have recently been decorated and the manager informed the inspector that this process would continue. The registration certificate was up to date and on display. The kitchen is located in 7a Mapesbury Road, which is not part of Jewish Care anymore and the food is transported to 7B via a lift. The carpet on the second floor was very used and should be replaced. There is a separate budget for repairs and replacements available in the home. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 16 The home was clean and free of any offensive odours during this inspection. Different policies regarding infection control, Health and Safety, COSSH, etc. are available. Kitchen staff was wearing aprons and regular checks of temperatures are in place. The home has two laundry areas one which can be used by residents and one, which is for staff to wash linen and towels. Both rooms have impermeable flooring and a semi professional washer and dryer. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Staff receives appropriate training and a well-trained staff team supports residents. EVIDENCE: Staff receives a detailed induction programme, including training in medication, first aid, fire safety, manual handling, etc. It was evident in the homes’ business plan that money is available for NVQ training, special mental health training and training supporting residents changing needs. Training needs are addressed in staff supervisions and all staff has a training and development plan available. Staff confirmed having received regular training in the past and a future training list was available for inspection. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Residents’ safety, health and welfare are protected and the home has a very good Health and Safety record. EVIDENCE: The inspector viewed the homes certificates gas, electrical wiring, portable appliances, etc. All viewed certificates were up to date, the manager provided a checklist of when certificates will expire, which is good practice and commendable. All fire records viewed were up to date regular fire drills, fire checks and servicing of equipment, were clearly recorded. The home has a number of Health and Safety policies in place, e.g. COSSH, Food Hygiene, Infection Control to name just a few. The home has individual risk assessments in place for residents using cookers in their flats. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 19 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Jewish Care Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 4 x G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 20 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. 2. 3. Standard YA6 YA20 YA22 Regulation 15(2)(a) 13(2) 22(6)(a) Requirement Care plans must be provided in a format suitable to residents. It is required to record residents allergies in the MAR sheet. The CSCI new title must be included in the complaints procedure. Timescale for action 15/07/05 30/06/05 31/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA9 YA24 Good Practice Recommendations It is recomended involving residents in the risk assessment process. The carpet on the second floor hallway should be replaced. Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex HA1 1BH 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 Jewish Care G62 G11 S17467 7B Mapesbury Road V226818 250505 Stage 4.doc Version 1.30 Page 22 - 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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