Inspection on 11/09/07 for Rosa Freedman Centre

This inspection was carried out on 11th September 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

Rosa Freedman Centre 19/10/06

Rosa Freedman Centre 16/02/06

Rosa Freedman Centre 13/09/05

Rosa Freedman Centre 17/01/05

Rosa Freedman Centre 13/09/04

Similar services:

Spinney (The)

Queen Elizabeth House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Rosa Freedman Centre 17 Claremont Way Cricklewood London NW2 1AJ Lead Inspector Jane Ray Key Unannounced Inspection 11th September 2007 10:00 X10015.doc Version 1.40 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 Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosa Freedman Centre Address 17 Claremont Way Cricklewood London NW2 1AJ 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) 020 8458 0591 020 8731 6174 manager.rosafreedman@freemantletrust.org Manager.ladyelizabeth@fremantletrust.org The Fremantle Trust Mrs Emma Julie McAfee Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 18 adults of either gender who fall into the category of old age (OP) and who may have dementia (DE(E)). 19th October 2006 Date of last inspection Brief Description of the Service: The Rosa Freedman Centre is a care home registered to provide care for 18 older people, some of whom may have been diagnosed with dementia. One of the places is used to provide respite care. The home is part of a complex that includes a day centre and a sheltered housing scheme. Barnet Council used to run the complex and The Freemantle Trust and Catalyst Communities Housing Association have now respectively taken over responsibility for the care and property services in the residential home and day centre. The local authority retains responsibility for the sheltered housing scheme. The care home was purpose built in 1989. There are two nine-place units with identical accommodation on the ground and first floors. Stairs and a passenger lift link the two units. Both units have nine single bedrooms, a kitchen/diner linked to a lounge, a separate lounge, a bathroom, a shower room and four toilets. The general staff facilities are on the first floor and the main kitchen/restaurant serves the home and day centre and is situated on the ground floor. There is a pleasant, accessible garden to the rear of the home. The Rosa Freedman Centre is in a quiet road next to a park. Local shops are nearby as is the Brent Cross shopping centre. There are good transport links. The stated overall aim is to provide a high standard of care and support that is tailored to meet individual needs taking into account each service users right to exercise choice and self-determination in pursing their own lifestyle. The provider must make information available about the service, including reports, to service users and other stakeholders. The fees for the home are £545 per week. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 11 and 12 September 2007 and was unannounced. The inspection took 10 hours to complete. The inspector did a tour of the entire service accompanied by the manager. The inspector then spent the majority of the inspection focusing on the two flats. In each flat the inspector spoke at length to at least one or two of the residents and visitors. The inspector also interviewed one member of the care staff in each flat as well as speaking to other care staff who were working at the time. The inspector also looked at four care plans and the medication systems in each of the flats. The inspector also used a method of observation over a two-hour period for the upstairs flat in order to get a better understanding of the resident’s experience of living in this service. This is called the ‘Short Observational Framework for Inspection (SOFI). This involved observing 4 people who live in the flat and recording their experiences at regular intervals. This included their state of well being, and how they interacted with staff members, other people who use services, and the environment. The quality of the staff interaction with the residents was also noted. The inspector also looked at all the relevant records including service user finance records, staff files and health and safety information. The home also prepared a self–assessment (AQAA) and this was submitted to the Commission for Social Care Inspection prior to the inspection. The inspection is the annual key inspection and the aim is to look at how well the service is meeting the key National Minimum Standards for Older People. The inspector would like to thank the service users and staff for their assistance with the inspection process. What the service does well: The people living in the home were very positive about the service they receive and one person told the inspector “we are all like a family”. Visitors are made very welcome when they come to the home. There was a very warm and friendly atmosphere in the home and it was observed that the staff related very positively to the residents. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 6 The inspector could observe that the staff were very positive about their work and had a good knowledge of the individual needs of each of the people living in the home. The manager is very “hands on” and several of the residents said they found her very “nice” and “helpful”. She is a positive role model and is supportive and enabling with the staff team. The residents are supported to maintain their independent living skills in the home based on their individual needs. The physical environment throughout the home was clean and comfortable and the bedrooms are very personalized and homely. The gardens were well maintained and a source of pleasure for the residents. Many of the people said how much they enjoyed the food provided in the home and felt able to ask for an alternative if they did not want what was on the menu. The care plans and risk assessments for each person were updated and reflected the needs of each individual. These showed that the home works closely with other healthcare professionals when this is needed. What has improved since the last inspection? At the last inspection there were eight requirements. Whilst work has started on all the requirements four have been completed. The menu offers a choice of food including salads when requested. The homes training matrix that records the training that staff have received was up to date apart from some training that had just taken place. The staffing levels had been reviewed to reflect the dependency levels of the residents and this had resulted in a proposed change in the rotas to increase staffing levels at busy times. The length of the call bell cords had been reviewed but making them longer was presenting a trip hazard. The residents said they felt able to reach the call bell. The requirements that needed further work were as follows. A new rota had been prepared to ensure two staff were on duty in each of the flats at busy times but this still needed to be implemented. Progress had been made in ensuring staff had received the mandatory training but there were still some gaps particularly for fire safety training. More night staff had received training but are still falling behind the day staff in terms of the numbers of courses they have attended. The activities particularly for people with dementia need further work and this has been linked to a vacant activity co-ordinator post although recruitment is underway. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,4 and 5 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People moving to the home can be assured that they will be assessed, given information about the home and be able to visit the service to decide if they want to move there. The staff team have great deal of skill and experience particularly in caring for people with dementia. EVIDENCE: I read the homes statement of purpose and service user guide. They provide information to people thinking of moving to the service, relatives or other care professionals. I also saw a two page “flyer” that is being prepared to give to potential residents and this is a really useful, accessible and person centred summary of the service. The statement of purpose needs to provide more information to reflect the input that can be provided to people with dementia. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 10 I looked at the assessments completed for two people living in the home. They all had a detailed assessment prepared by social services at the time of their admission. Once they had arrived at the home an assessment was completed covering all their individual needs. This also included information such as their preferred routine and their life story. I discussed the process of moving to the home with the residents and care staff. They explained that the people who live in the home normally are able to visit often with their relatives and some may come for a day visit. One resident explained that she had attended the day service before moving into the residential service and so she knew the home, which made the move easier. I looked at the contracts between the home and the residents for four people living in the home. All of these documents were completed correctly and included the number of the room being offered to the resident and were appropriately signed. I discussed respite care with the manager. The home provides one respite bed and this was empty at the time of the inspection. This bed does not offer rehabilitation and are therefore is not an intermediate care service. I spoke to the staff about the needs of the people living in the home and then looked at the training they had been offered. All the beds in the home can be used for people with dementia, although the current residents have a range of individual needs. Twelve of the fourteen permanent residential staff had attended internal courses on how to support people who have dementia, which they said they had found very useful. A senior manager who has been trained to be a trainer by the Alzheimer’s Society delivers this training. In addition this senior manager also carries out a dementia mapping exercise at the home every six months to look at how care is delivered to the people who have dementia. A senior carer in the home has also been trained as a “dementia champion” and provides new staff with training using a specially prepared induction pack. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and wellbeing of the people living in the home is well maintained. Risks are assessed and service users treated with respect and their privacy protected. Some people need further support to access dental checks and guidelines for the administration of PRN medications need to be in place. EVIDENCE: I looked in detail at two care plans in each of the flats. Each care plan is very person centred. The care plans are holistic and not only covered the persons healthcare and support needs but also looked at their emotional needs including significant relationships. Where possible the care plans are signed by the resident. The care plans had been reviewed on a monthly basis. Each care plan included an individual risk assessment that always included a moving and handling assessment. Other areas of risk were also covered such as domestic Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 12 activities, going out and medication. The home operates a key-working system and the staff who were interviewed showed a good understanding of their keyworking role and the residents all knew the name of their key-worker and found this person very helpful. The residents had each had a review meeting with their care manager in the previous year, apart from one person who had not yet lived in the home for 12 months and it could be seen that action agreed at that meeting was being addressed. Three of the four care plans included a “life story”, which was very useful for staff in building a good understanding of each person. It is recommended that these are completed for everyone. I looked at the healthcare records for each person whose care plan was inspected. Each person has a record of the healthcare appointments they attend. The records indicated that the people living in the home see the GP, district nurse and optician on a regular basis. They are also supported to see appropriate specialists where required, for example one person had attended the audiology clinic. Only one of the four residents had a record of having a dental check. The manager explained that the home no longer gets a regular domiciliary service and that now individual referrals need to be made. She explained that a number of referrals had been sent but they were now waiting for a service. I could however see that where there was a specific dental problem this was being addressed, for example one person had lost their dentures and arrangements had been made to organise a replacement. Each person had a nutritional assessment and had been supported to have their weight checked on a monthly basis or more regularly if necessary. At the time of the inspection, the manager explained that none of the people living in the home had a pressure sore. I did however look at the care plan for a person who had been treated for a pressure sore and now had preventative measures in place. His care plan addressing these healthcare needs was comprehensive. The medication and the administration records were inspected in the two flats. The home uses the Boots blister pack administration system. Each flat has their own trolley and the trolleys are stored an air-conditioned room. Staff were observed administering the medication appropriately during the inspection. Thirteen of the fourteen permanent staff have received medication training. I looked at the medication records. These showed that the medication administration records were being completed and signed appropriately. The individual medication profiles for each person and photos were in the process of` being updated at the time of the inspection. All medication received and returned is recorded on the administration records and so there is a clear audit trail available of the medication. The only concern was that one person had PRN medication for a particular healthcare need and there was no written protocol in place for when it should be administered. It was also recommended that each medication administration file contains a list of staff signatures. One resident self-administers her medication and an appropriate risk assessment is in place. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 13 The people living in the home and a visitor spoken to during the inspection were full of praise for the staff. One resident said “I think the staff are very caring”. Another said “the staff always listen to me”. I observed that all the personal care was given in a manner that preserved the privacy and dignity of the people living in the home. Everyone was appropriately dressed and were able to access the hairdresser who visits the home. The staff were observed to be friendly and able to share a joke, whilst treating people in a respectful manner. The SOFI exercise indicated that for most of the two-hour period the residents who were observed were generally in a positive mood state. The engagement of the residents was mainly with staff and was largely focused on having lunch, although the residents also had some contact with each other and visitors during this time. The staff interaction was generally good and they showed warmth, respect and were also enabling the residents to enjoy their lunch. There was one member of staff who was speaking to a resident in a kind but slightly child-like manner and the manager later explained that this person is employed as a domestic but as she helps at lunch-time is also going to attend the dementia training which should improve her use of language. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were inspected. People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home find that the service can meet their cultural and religious needs, support them to maintain contact with their relatives and offer them a healthy diet. Residents are supported to contribute their ideas at regular meetings. The absence of an activity co-ordinator in the home means that activities are not taking place as regularly as the residents might wish. EVIDENCE: It was observed during the inspection that people living in the home were able to follow their own routine, getting up more slowly if they wished to do so and spending time in their bedrooms if they preferred. Two of the residents said they liked to stay up later and watch TV in the lounge. At the time of the inspection there was no activity co-ordinator in post and the residents said that they were missing this input. Occasional outings are taking Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 15 place and on the second day of the inspection some of the residents from the flats were going out for a pub lunch. In addition the staff and residents explained that they discuss what is happening in the news, watch videos and listen to music. There are no activities at present that specifically meet the needs of people with dementia. Two residents said they were looking forward to a new activity co-ordinator coming into post. The manager explained that the post has been advertised and there are applicants who will be interviewed. The people living in the home are supported to maintain their independence. Everyone is encouraged to make themselves a hot drink whenever they wish to do so. One person has got an ironing board in her bedroom so she can do her own ironing. The home strives to meet peoples religious and cultural needs in line with their individual wishes. The manager explained that a church service takes place once a week at the home and that some Catholic nuns also visit weekly. Another resident sees his priest individually. The care staff explained that different food can be provided according to peoples religious or cultural needs. The catering staff, also prepare meals for the day centre where the users have a number of dietary needs linked to their religion including a service for Asian people. At the time of the inspection all the people living in the home spoke English but the staff explained that the staff team are also culturally diverse and can often facilitate in communicating with people where English is not their first language. Visitors were observed coming to the home during the inspection and were able to spend time with people in the lounge or their bedrooms. I was able to speak to one visitor who said she always felt welcome in the home and was offered a cup of tea. From discussions with the staff and residents I could see that most people had contact with relatives and friends and that the staff supported these relationships. One resident told me how she likes to go and visit her daughter each week. It was observed that most of the rooms were personalised and that people had brought with their possessions into the home. The inspector observed that the people living in the home were able to talk to the staff and express their wishes about their daily lives. The home also has a residents meeting that meets every two months. The minutes of these meetings were inspected and they discussed changes in the home, activities, health and safety issues and meals. The manager explained that most of the people living in the home have relatives who act on their behalf if needed, but an advocate from a service called Barnet Support has recently supported one resident. The home follows a four-week rolling menu and I was able to see the lunch being served on the first day. Three meals are provided each day and regular Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 16 hot drinks in between. The people living in the home were very positive about the food and said alternatives are always available if they want something different. One resident said “if you don’t like fried fish they will always make you steamed fish”. Fresh fruit and salads are available as part of the menu. The residents said that the suppers have improved over the last month. As part of the inspection I was able to observe lunch on the first day and could see that this took place in a relaxed and sociable manner. Staff support was given in a helpful and discreet manner. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home have access to an effective complaints procedure. They are also protected by most of the staff having completed training on the protection of vulnerable adults. EVIDENCE: I looked at the complaints procedure, which forms part of the Fremantle feedback process. This process is clearly explained and is given to every person in the home as part of the introductory pack. I also looked at the record of complaints and in the last year there have been four complaints of which three have been substantiated. I felt that it was positive that the complaints were both written and verbal and were being appropriately acknowledged and addressed. The outcomes of the complaints were clearly recorded. The residents spoken to said that if they had any concerns they would speak to their key-worker or the manager. The home has an appropriate policy and procedure in place for the protection of vulnerable adults. The staff spoken to, demonstrated a good understanding of how to recognise abuse and what action they would need to take. The staff training records showed that all staff covered training on adult protection Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 18 issues as part of the staff induction and then eleven of the fourteen staff had also completed a separate training session. I also looked at the systems in place to support the residents to manage and safeguard their personal monies. Relatives assist most of the residents but four are supported by Fremantle in this area. Each person has a record as part of their care plan explaining how his or her personal finances are managed. I looked at the monies for two residents with the support of the administrator. People have a separate account and their pension is paid into the account. There is a receipt available for each item of expenditure. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,23,24,25 and 26 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Rosa Freedman is a purpose built service and provides a comfortable and safe environment for the people who live in the home. The building is older and a gradual programme of improvements is in place. EVIDENCE: Rosa Freedman is an older purpose built home with accommodation available on the two floors. The building is divided into two flats and also has a large day centre. Each flat consists of a lounge /dining area and small kitchen as well as a small second lounge and all the bedrooms. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 20 Whilst the home is not designed to be a secure unit the front door does have exit buttons that need to be pressed in order to open the doors and this safeguards people with dementia who may be at risk of wandering as well as ensuring people do not enter the home uninvited. Rosa Freedman has an attractive landscaped garden that can be accessed by the flats and the day centre. This garden includes raised flower-beds and the residents are planning to have a vegetable patch next year. The building appeared well maintained and the manager explained that in the last 12 months the hairdressers room has been retiled, a dangerous tree has been removed in the garden and slabs re-laid, the kitchen diners have been decorated and work on the boilers has taken place. Ongoing maintenance plans include work that will take place to refurbish a bathroom and two toilets and redecorating some bedrooms. Both the main lounges benefit from flat screen televisions and the residents commented on how much they enjoy these televisions. All the bedrooms in the home are single and very spacious. The bedrooms are all appropriately equipped. It was very positive to see that residents had brought lots of their personal possessions with them into the home. Each flat also has a bathroom, shower room and separate toilet. The heating and lighting throughout the home was appropriate although the inspector was unable to tell what the temperatures would be like during the very hot weather, but did note that fans were in use in some areas. The premises were clean and tidy throughout and there were no unpleasant odours. The laundry was appropriately equipped and suitable arrangements were in place for the washing of foul laundry. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were inspected. People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by a stable and experienced core of staff, but staff vacancies need to be filled and shift patterns changed to ensure there are adequate numbers of experienced staff available at all times. EVIDENCE: The staffing structure for the flats consists of the manager, three group care leaders and a team of carers. Each flat has 30 hours of domestic staff support each week and there is also a part-time laundry assistant. A catering team prepare the lunch each day and provide food for the suppers. The care staff in the flats, prepare breakfast and supper. I looked at the staff rota’s, spent time on both flats and spoke to staff and visitors in order to inspect staffing levels. The manager explained that at the time of the inspection there were 124 vacant care staff hours out of a total care staff establishment of approximately 476 hours a week. This excludes group care leader staff who also spend time supporting the residents. A recruitment campaign has taken place and three “as and when” staff, have been offered posts, which it is hoped will reduce the vacant hours. The manager explained that in the past four weeks 66 shifts have been covered by Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 22 agency staff, which works out as an average of 115 hours a week. It was observed during the inspection that there was one member of staff from an agency and that she was not working so effectively with the residents and during lunch spent most of the time doing the washing up. The home is in the process of introducing a new shift system. Currently there is one member of staff working in each flat and a third member of staff who floats between the two flats. At night there are two waking staff and a member of staff sleeping-in. The manager has identified that due to the increased dependency of some of the residents that there always needs to be two staff at busier times, such as in the morning, at lunchtime and at suppertime and early evening. A new shift pattern has been proposed but still needs to be implemented. The manager explained that at the time of the inspection 8 care staff had completed the NVQ in care and 2 care staff are working towards the qualification. This means that over 50 of the staff have completed or are studying for an NVQ in care, most of whom are being supported by the Fremantle NVQ assessment centre. I looked at the recruitment checks for five members of staff. They all had an application form, two written references, photographic ID and a CRB check. One member of staff had no evidence of a visa giving permission to work in the country and two staff had visa’s that had expired in their staff records. All the staff had completed and signed contracts of employment. I looked at the training records for five members of staff and at the staff, training matrix for the whole staff team. The staff employed in the last few years all have a record of a completed induction but staff employed many years ago do not have an induction record. The induction is very thorough and includes training on how to promote each resident’s rights, choice, privacy, individuality, dignity and respect. It also promotes the concept of person centred care. The staff team, training matrix was up to date with the exception of some moving and handling training that had just taken place. The matrix did however show that the night staff, have still not attended the same number of courses as the day staff. The manager said they are looking at how this can be addressed. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,36 and 38 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in this home benefit from the service being well managed. They also have an opportunity to contribute their point of view through the quality assurance process. Repairs to the emergency lighting needs to be completed and a few staff need to undertake fire safety training. EVIDENCE: The registered manager has extensive skills and experience. She has completed the Registered Managers award and waiting for an assessor to be available in order to complete her NVQ level 4. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 24 The manager during the inspection demonstrated an excellent knowledge of all aspects of the service she manages and was observed to have an open and inclusive style of management with the staff team in the home. The residents spoke very positively of the manager and said she was very helpful. There is a clear management structure within the home. Monthly staff team meetings take place and discuss a range of operational issues. I looked at the quality assurance exercise that was completed in November 2006. This consisted of a detailed quality audit completed by Fremantle senior managers looking at all aspects of the operation of the home, and questionnaires that went to residents, relatives, staff and care professionals. The results and comments received had been collated into an action plan. I looked at the records of the regulation 26 visits by senior managers from the organisation. These are taking place on a monthly basis and different senior managers visit the home to carry out the checks. I looked at the supervision records for five members of staff. These show that whilst individual supervisions are taking place they are not yet happening regularly. The health and safety records were inspected. In terms of fire safety the fire alarm and fire extinguishers had all been serviced. The emergency lights were waiting to be repaired as the main battery needed to be replaced and the manager did not have a date for when this work would be complete. The emergency plan is in place and the fire alarm is being checked on a weekly basis. The fire safety risk assessment is in place but only two fire drills have taken place since the beginning of the year and it is recommended that these take place at least quarterly. Only eight out of the fourteen permanent staff had completed fire safety training. The maintenance certificates for the electrical appliances, electrical installations, gas boilers, lifts, hoists and water system check for legionnaires were all in place. The staff training records for health and safety were inspected. Almost all the staff had completed training on first aid, food hygiene and moving and handling. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 3 x x 2 x 2 Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 4(1) Requirement Timescale for action 31/10/07 2. OP9 13(2) 3. OP12 16(2) 4. OP27 18(1) The Registered Persons must ensure that the statement of purpose includes details of how it meets the needs of people with dementia. The Registered Persons must 30/09/07 ensure that where a resident has PRN medication that there are clear guidelines about when this should be administered. The Registered Persons must 31/10/07 ensure that all the residents have access to activities in line with their individual interests and activities for service users with dementia are developed and advanced. This requirement is amended and restated. Previous timescale of 28/02/07 was unmet. The Registered Persons must 31/10/07 ensure that sufficient staff are on duty at all times and that the staffing levels increase at busier times such as when people are getting up or going to bed and at mealtimes. This requirement is amended and restated. Previous timescale of DS0000010522.V345634.R01.S.doc Version 5.2 Rosa Freedman Centre Page 27 5. OP27 18(1) 6. OP29 19(1)-(5) 7. OP30 12(1) 8. 9. 10. OP31 OP36 OP38 9(2)(b) 18(2) 23(4) 31/12/06 was unmet. The Registered Persons must complete the recruitment of staff to reduce the number of vacant staff hours and the use of agency staff. The Registered Persons must ensure all the staff all have current visa’s where needed, that give them permission to remain and work in the country. The Registered Persons must ensure that all night staff are fully integrated into the home’s training programme. This requirement is restated. Previous timescale of 31/12/06 was unmet. The Registered Persons must ensure the manager completes the NVQ level 4. The Registered Persons must ensure all the staff are supported to have regular supervision. The Registered Persons must ensure the emergency lighting is repaired and that the staff all complete fire safety training. 31/10/07 31/10/07 31/12/07 31/01/08 31/10/07 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP8 OP9 Good Practice Recommendations The Registered Persons should prepare life stories for all the residents. The Registered Persons should complete the process of referring residents for dental input. The Registered Persons should complete a list of signatures for the medication administration records. DS0000010522.V345634.R01.S.doc Version 5.2 Page 28 Rosa Freedman Centre 4. OP38 The Registered Persons should increase the frequency of the fire drills so they take place on a quarterly basis. Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rosa Freedman Centre DS0000010522.V345634.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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