Inspection on 13/09/05 for Rosa Freedman Centre

This inspection was carried out on 13th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rosa Freedman Centre 11/09/07

Rosa Freedman Centre 19/10/06

Rosa Freedman Centre 16/02/06

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 Margaret Flaws Unannounced Inspection 13th September 2005 10:00a 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.V249239.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 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.V249239.R01.S.doc Version 5.0 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 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.V249239.R01.S.doc Version 5.0 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)). 17th January 2005 Date of last inspection Brief Description of the Service: BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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 Ealing Family 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. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately six hours. It was undertaken by Inspector Margaret Flaws, as part of the routine schedule of inspections for the home. The care manager and six staff of Rosa Freedman were spoken to on the day of the inspection. The inspector was also able to speak to seven service users. No relatives visited during the inspection. A tour of the buildings and grounds, inspection of service user files, staff records, general home records and policies and procedures formed the basis of the inspection. Four new requirements were made on this inspection and none were restated from the last inspection. What the service does well: What has improved since the last inspection? What they could do better: There are four new requirements arising from this inspection. The additional medication storage cupboard on the first floor was found to be too hot and measures should be taken to control the temperature. All staff, including night and bank staff, must complete adult protection training. The downstairs toilet is in a poor state of repair and needs refurbishment. Broken tiles must be replaced in the sluice room as they represent an infection control hazard. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 6 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. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 7 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.V249239.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users can feel confident that their needs will be fully assessed prior to admission to ensure that the home is appropriate for them and that their needs can be met. EVIDENCE: The care plans of four service users (two upstairs and two downstairs) were examined. All contained comprehensive assessment information in sufficient detail to identify and meet service users’ needs. The front page of each service users’ file contained a summary life history, which, while succinct, provided an excellent introduction to their needs. Service users with dementia had very thorough needs’ assessments and all service users had regular documented reviews by the placing authorities. The home does not provide intermediate care. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Service users can be confident that their needs will be fully assessed and that necessary information is conveyed to staff in an original and professional manner. They can also be confident that their privacy will be respected and that medication policy and procedures will be generally adhered to. EVIDENCE: A sample of four care plans were inspected. These care plans were detailed, had specific objectives and were reviewed regularly in consultation with the service users. Risks assessments on areas like dementia, tissue viability and nutrition were clear and updated monthly, and as and when. As recorded in standard three, the life history front page gave some of the best information on service users that this inspector has seen to date. Key working staff were very knowledgeable about the needs of the service users they were responsible for. Health needs were comprehensively covered in care plans. Care is supplemented by district nurses, GPs and community care teams. The degree of independence and mobility of service users at the time of the visit was generally good. Only three service users needed to use a wheelchair and their Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 10 mobility issues were appropriately assessed and catered for. Regular health checks are planned, completed and recorded. The medication storage facilities are appropriate for the home. There are locked cupboards on both floors and a medication fridge in the staff room. There is also an additional storage cupboard which was found to be too hot (28 °). This temperature must be reduced. Staff were observed administering lunchtime medications and MAR charts were examined and these were in order. A new system of double checking medication by the assistant manager and duty manager has been introduced to minimise errors, after an error identified at the previous inspection. Feedback from the service users on the provision of their personal care was very positive. Staff described how they provided personal care to several service users and demonstrated a clear knowledge and understanding of the their privacy needs. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Service users know that the options for a reasonable lifestyle will be provided by the home and that they will have some choices for day to day activities. They also know that the home provides them with a healthy and interesting food options. EVIDENCE: Most service users were at home during the inspection. Some spent the day in the day centre which is in another part of the building. Others spent time watching television, reading and talking. Service users have the option of going on outings and activities outside of the home. The home currently has a vacancy for an Activities Coordinator. This position was recruited to but fell through. This has resulted in some limitations on activities within the home and the curtailment of some activity plans in the interim period. All service users spoken to said they could choose how to spend their days and that there were good lifestyle options available that they could utilise if they wished. Food arrangements at the home involve food being bought to each unit on heated trolleys. Staff plate and serve these meals individually to the service users in the dining rooms. Lighter meals at breakfast and in the evening are Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 12 prepared and served by staff in these kitchen/dining areas. The lunch served was healthy, nutritious and tasty. Menus examined had several choices and a regular rotation. Some service user required assistance to eat and staff were seen to be considerate and respectful of their needs. All service users spoken to during lunch said that they like the food and the service users’ meeting minutes for July 2005 contained positive comments about the food. The chef said that the kitchen was reasonably well resourced to provide good quality food and described how service users were consulted on their food preferences and dietary needs. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 There is a sound complaints policy and procedure to protect the service users’ interests and they can be assured that staff will actively support them in the process of any adult protection concerns. EVIDENCE: The home’s complaints policy and procedures and complaints book was examined. There was evidence of a clear process being followed, both in investigation and outcome reporting. The Fremantle Trust’s adult protection policy and procedure is clear and easy to follow. In the period prior to and concurrently with the inspection, the home has been dealing with an adult protection issue involving current service users. The issue has been very well risk managed: local authorities involved, protective measures put in place and strategy meetings held. While the situation had not been resolved at the time of writing, the inspector is confident that the outcome will reflect the home’s skill in managing this difficult issue and that the welfare of service users will be protected. All staff spoken to were able to describe the adult protection issues involved and how they supported services users. The home has provided one to one staffing for one service user while the matter is resolved. Most staff have either received POVA training as part of the home’s training programme (or are booked for a session in November 2005), and through NVQ study. The manager said adult protection is highlighted in staff meetings Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 14 and supervision sessions. However, some night and bank staff have not received adult protection training since 2002 and are required to receive this training. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Service users live in a well maintained, reasonably fitted out home which requires very minor improvements and is generally clean and hygienic. EVIDENCE: The home is maintained to a good standard. Two service users showed the inspector their bedrooms, which were extremely comfortable and highly personalised. Communal spaces were also very comfortable and well resourced. One downstairs toilet was obviously in need of refurbishment, which is required. Hygiene arrangements were inspected and were in order. Laundry facilities are suitable for a home of this size and dedicated laundry staff are employed. To preserve the health and safety of service users, damaged tiles in the sluice room must be replaced. There is an appropriate infection control policy and procedure. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 16 Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Service users can be confident that they will be supported by safe, competent and well trained staff. EVIDENCE: Staff rotas were examined. There were sufficient staff on duty on all shifts. The first floor has the highest dependency level and a floating member of staff spends most time there. There is particularly good on site management cover for all shifts, including night shifts. Staff turnover in the home is low and staffing very stable, leading to good continuity of service. Staff meetings for each layer of staff are held regularly at times appropriate to the working times of staff. Five staff files were examined. The home’s recruitment procedure is clearly robust and all elements required in the Schedule 2 were in place in each file, including in the files of the most recently recruited worker. All staff had up to date CRB checks on file. Staff training files were examined. Staff training is well documented both in individual files and in a generic staff training file. All mandatory training is up to date. There is a very sound care specific training programme which covers the care needs of the service users, such as stroke, epilepsy, arthritis, parkinson’s disease, dementia and securing passengers in wheelchairs. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 18 Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 38 Service users are protected by sound management and health and safety practices. EVIDENCE: The Registered Manager Emma McAfee is completing the Registered Manager’s Award. Staff and service users said the home was very well run and managed. Staff described a responsive management environment that had moved over the years from an “us and them” culture into something more inclusive. All building and health and safety certificates inspected were up to date and in order. The inspector spoke to the person responsible for maintenance, who said that the home had a good repair and improvement cycle and that he was well resourced for his job. The incident and accident reports were examined and demonstrated good evidence of contributing to a quality improvement Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 20 process. Staff were observed following the incident reporting procedure after an injury to a service user with a minor injury and they handled the process thoroughly and professionally. Fire safety procedures were examined and were in order. Regular checks and fire drills are held. Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X 3 Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 (2) Requirement Timescale for action 13/10/05 2 3 OP18 OP19 13 (6) 13 (4) 4 OP26 13 (4) The Registered Person must ensure that the temperature in the medication cupboards does not exceed 25°C. The Registered Person must 30/11/05 ensure that all staff receive up to date adult protection training. The Registered Person must 30/11/05 ensure that the downstairs toilet in need of refurbishment is refurbished. The Registered Person must 30/11/05 ensure that broken tiles in the sluice room must be replaced. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Rosa Freedman Centre DS0000010522.V249239.R01.S.doc Version 5.0 Page 24 - 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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