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Inspection on 16/02/06 for Rosa Freedman Centre

Also see our care home review for Rosa Freedman Centre for more information

This inspection was carried out on 16th February 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Rosa Freedman provides a very good standard of care for service users. The home is well managed and resourced, with sound policies and procedures put into practice . While there has been some use of agency staff recently, the home has a solid and positive organisational culture to carry it through these occasional periods of staff instability and to resource temporary staff appropriately. A good example of innovation has been the way the home has drawn on its own staff resources and talents in the continuing absence of an Activities Coordinator. The home is also developing ways of involving service users in its staff recruitment process.

What has improved since the last inspection?

There were four requirements made at the last inspection. After medication cupboard temperatures were found to be too hot, this medication has now been moved to a new clinical room, which will be air-conditioned. Staff have completed adult protection training. A downstairs toilet has been repaired and broken tiles replaced in the sluice room.

What the care home could do better:

Five requirements were made at this inspection. Some service users` weight monitoring charts were not kept up to date, as is required.Fire drills should be held a minimum of four times per year and recorded. The cupboards storing the washing machine pump needs repairing to ensure that the pump is covered. The archive room where medication is now housed requires reordering because it is now in daily use. It is also required that staff facilities for night management cover be improved.

CARE HOMES FOR OLDER PEOPLE Rosa Freedman Centre 17 Claremont Way Cricklewood London NW2 1AJ Lead Inspector Margaret Flaws Unannounced Inspection 16th February 2006 09:00 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.V271095.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.V271095.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 Manager.winglodge@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.V271095.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)). 13th September 2005 Date of last inspection Brief Description of the Service: Sum_Services SERVICES PROVIDED. BRIEF DESCRIPTION OF THE 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.V271095.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. It was undertaken by Inspector Margaret Flaws, as part of the routine schedule of inspections for the home. The Registered Manager and three staff were spoken to on the day of the inspection. The inspector also spoke to five service users and one relative. 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. Five 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: Five requirements were made at this inspection. Some service users’ weight monitoring charts were not kept up to date, as is required. Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 6 Fire drills should be held a minimum of four times per year and recorded. The cupboards storing the washing machine pump needs repairing to ensure that the pump is covered. The archive room where medication is now housed requires reordering because it is now in daily use. It is also required that staff facilities for night management cover be improved. 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.V271095.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.V271095.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, both permanent and respite, can be 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: There home has had five admissions since the last inspection. Six care plans were inspected. 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 provides regular respite care placements and there was no variation in the quality of assessments and information provided on these service users. Because there is a day centre in the same building, referrals are often made for respite and permanent placement for service users from the day centre. The Registered Manager said that there is good continuity of care in these circumstances, for example, the new service user’s key worker from the day centre continues to support and help to settle them into the home. Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 9 To meet the needs of all service users, the Freemantle Trust has policies on diversity and staff have equal opportunities training as part of their induction. These will be inspected fully at the next inspection. The home does not provide intermediate care. Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 10 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, 10, 11 Service users can be confident that assessed information on their needs is provided to staff and translated into sound care plans, which are then put into action and regularly reviewed. They can also be confident that their medication will be safely stored, their privacy protected and that they will treated with care when they are dying. EVIDENCE: Six care plans were sampled. They were detailed, with 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 regularly updated. Two service users’ weight charts were not updated regularly and this is required. Observations and discussions with service users made it clear that their identified needs were consistently met. Staff spoken to, including agency staff, had a good understanding of the service users’ needs and how to action their care plans. They were observed to interact professionally and kindly with the service users and demonstrated respect for their privacy. Health needs were comprehensively covered in care plans. District nurses supplement care, along with GPs and community care teams. Regular health checks are planned, completed and recorded. On the day of the inspection, Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 11 some service users had the flu. Staff in the home were observed following good practice in supporting their healthcare needs and ensuring that good infection control procedures were followed. One service user is receiving palliative care, with input from community based teams, who have told the Registered Manager that they are pleased with how the home is managing this care. The home is working hard to improve care for people with dementia, with work on Dementia Care Mapping and improving activities for people with dementia. Service users said that staff treated them very well, with respect and protected their privacy. One relative reported that she was very pleased with the quality of care, the responsiveness of staff, and the standard of food ad cleanliness in the building. Medication requirements made at the last inspection, following a visit by the Pharmacy Inspector, have been met. The Registered Manager said that the medication storage arrangements have been changed, after it was identified that the room for the second medication cupboard on the first floor was too hot. Medications from this room are now stored in a new clinical room created in an old archive space. The room is still cluttered and a requirement is made that the space be reordered now that it is daily use. Air-conditioning is to be installed in the room. Medications from the main storage area on the first floor will also be moved into this room after two lockable trolleys are purchased. Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 12 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, 14, 15 Service users know that the options for a good lifestyle will be provided by the home and that they will have improved choices for day to day activities. Their families and friends are supported by the home to visit at any time. Service users are satisfied with the quality and nature of the food provided. EVIDENCE: Most service users were at home during the inspection. Some were unwell with the flu and were resting in bed or in their rooms. Others spent time watching television, reading and talking. The home is still recruiting for an Activities Coordinator. This position has been vacant since before the last inspection. The Registered Manager said that they have had great difficultly attracting someone to the post. In the interim, staff interests and abilities in leisure and activities have been audited and options that they can offer identified. Several staff have come forward to run some activities. One staff member does painting classes and service users are able to attend the day centre, which is at the end of the corridor in the same building. Another manager has undertaken a specialist course in activities for people with dementia. Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 13 The home is able to use the day centre facilities at night and on the weekends. They often have quizzes, games, creative classes and watch movies there. There are currently book club and reading groups, people go to the theatre, to the pub and to the movies, as well as on individual shopping trips. One staff member has become a Tai Chi trainer and will start classes for service users in March 2006. Service users spoken to were positive about what the home offered and said that they were able to choose how to spend their days. One service user said “it’s a happy home to be in, that’s what I think”. They all said that they felt well supported and cared for. Food arrangements were not inspected in detail on this inspection but service users said that they were happy with the choice and nutritional value of what was offered. One relative said that the food was “excellent” and that they could visit the home at any time. Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 14 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 interests of service users’ and their representatives and it is used effectively. The adult protection policy and procedures are also sound, and they are workable when required. EVIDENCE: The complaints policy and procedures, and recent complaints recorded were examined. There was evidence of a clear process being followed, both in investigation and outcome reporting. The home uses the complaints process to contribute to its quality improvement programme. The Fremantle Trust’s adult protection policy and procedure is clear and easy to follow. The home has resolved an adult protection issue involving current service users. A good outcome resulted from of the investigation and strategy meetings, and service users were protected. All staff have now received adult protection training, including night and bank staff, meeting a requirement from the last inspection. Rosa Freedman Centre DS0000010522.V271095.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, 21, 23, 24 and 26 Service users live in a well maintained, comfortable home and is clean and hygienic. EVIDENCE: The Registered Manager gave the inspector a tour of the building, which was maintained to a good standard. The inspector spoke to two service users in their bedrooms, which were of a good standard and highly personalized. There are several small and comfortable lounges in the home and the service users were observed making good use of them. All bathrooms have recently been redecorated and refurbished. A downstairs toilet was refurbished after a requirement was made at the last inspection. The Registered Manager said that they have problems over the winter with the home’s heating system and that they will be purchasing a new boiler. Regulation Thirty Seven reports were sent to the CSCI to report these problems. Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 16 Laundry facilities are suitable for a home of this size and dedicated laundry staff are employed. Damaged tiles in the sluice room have been replaced. A cupboard that holds the washing machine pump is in poor condition and requires repair. The home was clean and hygienic on the day of the inspection. Actions taken after an environmental health assessment last May were very thorough. Rosa Freedman Centre DS0000010522.V271095.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, 28, 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. There is normally one staff member on each floor and another staff member floats between the floors. There is always a manager on duty on site, night and day. There have been no new staff recruited since the last inspection but an NVQ3 student is currently doing a placement at the home and had all required checks completed. The Registered Manager said there are currently vacancies for one care staff member, an activities coordinator and a domestic. While staff turnover in the home is generally low and the staffing stable, agency cover was needed on the day of the inspection because of staff sickness and to cover an existing vacancy. The inspector spoke to an agency staff member, who was able to describe how the home had provided a good induction. The staff member had a good insight into the care needs of the service users and was familiar with the care plans. She also said that the staff were very good to work with, “they are very caring and they give me an opportunity to cooperate in important areas of the work”. The home’s recruitment procedure, which was examined at the last inspection, is robust. The home is exploring the options for involving service users in interviews for new staff. Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 18 The Registered Manager described the Freemantle Trust’s Policy and Procedure for agency staff. She said that each year, the Trust reviews agency staff performance and selects preferred providers for the coming year. For each new agency staff member, the agency must provide a form with training and referee details, a recent photograph, a copy of the current Criminal Records Bureau check. The organisation carries out spot checks on agencies to ensure that all records are kept. Staff training files were examined. All mandatory training was up to date and the home’s care specific training programme continues, covering, for example, stroke, epilepsy, arthritis, parkinson’s disease, dementia and securing passengers in wheelchairs. Recent staff training has included meeting the mental health needs of older people, medication, pressure care, falls prevention, infection control and person centred care. The night staff have recently had training in the care of the dying. Most day staff have NVQ 2 or 3, or in the process of completing these qualifications. The Registered Manager has completed her Registered Managers’ award and is now completing an NVQ4 in Care. She has also completed a course on Advanced Care in Medications. Two managers are qualified as POVA Trainers. Staff have all received adult protection training, which was required at the last inspection under Standard Eighteen. Rosa Freedman Centre DS0000010522.V271095.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, 32, 33 and 38 Service users are protected by sound management and health and safety practices. EVIDENCE: The Registered Manager Emma McAfee has completed the Registered Manager’s Award and is now completing an NVQ4 in Care. Staff and service users said the home was very well run and managed and were very positive about the qualities of the manager and other senior staff. In the most recent quality audit of the home indicated a need for improvement in activities and in the standards of the bathrooms. Action has already been taken in these areas, as has been described elsewhere in this report, and is continuing. Supervision arrangements were inspected and are good, with regular staff supervision covering key areas required and documented. One staff member said that, as well as formal supervision, informal supervision took place Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 20 weekly, was useful and enabled the staff deal with care issues and their practice in depth. All building and health and safety certificates inspected were up to date and in order. The home had Fire Risk Assessment in August 2005. Fire safety procedures were examined and were in order. Regular checks and fire drills are held but a recent drill was not recorded. This is required. Fire drills should be held at least four times per year. This is also required. Rosa Freedman Centre DS0000010522.V271095.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 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X X X X 2 Rosa Freedman Centre DS0000010522.V271095.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 2 Standard OP8 OP9 Regulation 14(1) 13(2) Requirement The Registered Persons must ensure that service users’ weight is monitored and recorded The Registered Persons must ensure that the new space dedicated for medication storage is free from clutter, tidy and easy to access. The Registered Persons must ensure that staff facilities are of a good standard. The Registered Persons must ensure that the cupboard housing the washing machine pump is enclosed and safe. The Registered Persons must ensure that fire drills are held four times per year, documented and reviewed. Timescale for action 30/04/06 30/04/06 3 4 OP27 OP19 18(3) 13(4) 31/05/06 30/04/06 5 OP38 23(4) 30/04/06 Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosa Freedman Centre DS0000010522.V271095.R01.S.doc Version 5.0 Page 24 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.V271095.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!