Inspection on 11/10/05 for Rosetrees

This inspection was carried out on 11th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Rosetrees 10/10/07

Rosetrees 18/04/06

Rosetrees 03/05/05

Rosetrees 03/11/04

Rosetrees 09/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Rosetrees Asher Loftus Way Colney Hatch Lane Friern Barnet London N11 3ND Lead Inspector Daniel Lim Unannounced Inspection 11th October 2005 09:10 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 Rosetrees DS0000010523.V251156.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. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rosetrees Address Asher Loftus Way Colney Hatch Lane Friern Barnet London N11 3ND 020 8920 4150 020 8920 4171 asamasuwo@jcare.org 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) Jewish Care Miriam Kajencki Care Home 57 Category(ies) of Dementia - over 65 years of age (57), Old age, registration, with number not falling within any other category (57) of places Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Rosetrees is a large purpose-built care home registered to provide personal care for a maximum of fifty-seven older people with dementia. It was opened in 2001 and is run by Jewish Care. The stated aims of the home are ‘ to provide appropriate individual care for older members of the Jewish community who either choose or circumstances require them to live in residential care.’ The home is a large detached three storey building with fifty seven bedrooms. All bedrooms are for single occupancy and have en-suite facilities. There are two lifts serving all floors. There are toilets and assisted bathrooms on each of the three floors. The kitchen, office, reception and main lounge / diner are on the ground floor. Additional lounges and staff offices are located on the other two floors. There is a car park at the side of the building. The gardens are located at the front and side of the home. They are accessible to service users. The home is located in a private road off Colney Hatch Lane. It is located close to local shops, public transport and other community services along Friern Barnet Road. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 18 October 2005 and took a total of 4 hours to complete. The inspector found that many of the National Minimum Standards had been met and the overall quality of care provided was satisfactory. During this inspection, the inspector was accompanied by the manager of the home (Amos Samasuwo). The inspector was able to interview five residents. The feedback received from them indicated that they were generally satisfied with the care provided. Statutory records including five residents’ case records, the maintenance records, accident records, complaints’ record and fire records of the home were examined. The premises including bedrooms, bathrooms, laundry, main kitchen (based at Lady Sarah Cohen House), gardens and communal areas were inspected. Staff on duty were interviewed on a range of topics associated with their work and staff training and recruitment records were examined. In addition, the minutes of residents’ and staff meetings were examined. What the service does well: The home was clean, modern and well furnished. Staff were described by residents as being polite and respectful. Essential training had been provided for staff. The home had a comprehensive programme of social and therapeutic activities. Meetings had been held for residents and relatives. There was evidence that their preferences had been responded to. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Further improvements must be made in the area of health and safety and maintenance of the premises. The registered person must arrange for fire drills to be organised at least once every three months. One of these must be carried out after dark. The registered person must request that an inspection be carried out by the LFEPA. A copy of their report together with details of any action taken must be forwarded to the CSCI. Weekly health and safety checks must be carried out. This must include checks on the condition of fire doors and exits. The registered person must arrange for safety inspections to be carried out by a qualified professional on all the portable electrical appliances, the gas installations, the hoists and assisted baths. Improvements are also needed in the area of healthcare. The registered person must ensure that the chiropody needs of all residents are attended to and the temperature of the room where medication is stored must be no higher than 25 C. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 7 Improvements are needed in the area of staffing. The registered person must review staffing levels (and the manner in which staff are deployed) with residents, relatives and staff to ensure that the needs of residents are met. A report of this review must be forwarded to the inspector . All staff records must contain satisfactory CRB disclosures. The registered person must ensure that the staff member who had not yet received a satisfactory CRB disclosure is only allowed to work under supervision. The registered person must ensure that the complaint brought to his attention during this inspection is fully investigated. A report regarding the outcome must be forwarded to the inspector. 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. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 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 Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 The manager and his staff had a good understanding of the needs of residents and were able to ensure that their needs were met. EVIDENCE: Five residents who were interviewed stated that they were generally well cared for and staff treated them with respect. Comments made by them included, “polite staff ”, “staff are well mannered”, “well treated” and “staff are responsive”. A sample of five residents’ case records which was examined contained comprehensive plans of care and details of how residents needs had been met. The inspector observed that residents in the home were clean, appropriately dressed and appeared well cared for. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 10 Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Residents had been treated with respect and arrangements were in place to ensure that the healthcare, personal, cultural and social needs of residents are attended to. Improvements are however, needed in the storage of medication and in ensuring that the chiropody needs of residents are attended to. EVIDENCE: Feedback from the five residents interviewed, indicated that residents’ healthcare needs had on the whole been met. Comments made included, “can see the doctor when needed” and “my medication had been given to me”. The sample of five case records examined were up to date and plans of care had been reviewed monthly. Records of medical and healthcare treatment were documented. A record of weekly GP visits had been maintained. Staff interviewed were knowledgeable regarding the care to be provided to residents. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 12 The temperature of the room where medication was stored had been recorded daily. This was not satisfactory as it was above 25 C. This must be kept below 25 C in accordance with guidance provided by the CSCI pharmaceutical advisor. The inspector further noted that the nails of four of the residents interviewed appeared long. These four residents stated that they would like to be attended to by a chiropodist. This was discussed with the manager and a requirement is made for their needs to be attended to. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 13 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 The daily life and routines of residents were well organised and met the cultural and social preferences of residents. Residents indicated that they were generally happy with the meals served. EVIDENCE: Residents interviewed were of the opinion that the home had activities which were appropriate. The home had an activities organiser and a programme of weekly activities provided for residents. This was seen by the inspector. The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. The kitchen was inspected and the arrangements for the provision of meals was noted to be satisfactory. Problems in the ventilation system had been rectified. The menu examined was varied and balanced. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 14 Residents interviewed stated that they had been visited by friends and relatives. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 15 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, 18 There was evidence that the rights of residents were protected and they had been well treated by staff. A requirement has however, been made for a complaint made by a relative during this inspection, to be investigated. EVIDENCE: The complaints record was examined. There was documented evidence that complaints recorded in the complaints book had been promptly responded to. Residents who were interviewed stated that they had been well treated. Comments made about staff included, “ staff are responsive”, “well treated”. A complaint was made by a relative during this inspection. This was discussed with the manager. A requirement is made in this report for the complaint to be investigated in accordance with the home’s complaints procedures and a report forwarded to the inspector. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 16 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, 20, 21, 22, 23, 24, 25, 26 The home was well equipped, clean and well furnished, therefore providing a nice environment to live in. EVIDENCE: The premises were inspected and found to be clean and well furnished. The hot water in bedrooms was tested and found to be within the required safe temperature range of no higher than 43 C. The gardens were attractive and seating had been provided. Not all the required maintenance records and safety certificates were seen by the inspector. These included the safety inspection certificates for the portable appliances and gas installations. These must be forwarded to the inspector. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 17 Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 18 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, 30 Staff were knowledgeable regarding their roles and responsibilities. However, a deficiency was noted in the recruitment procedure and concern was expressed regarding staffing arrangements in the home. EVIDENCE: The random sample of staff records examined, indicated that most of the staff were recruited with care and the required recruitment procedures had been followed. However, it was noted that the records of one staff member did not contain all the required documentation (ie. CRB disclosure). The manager explained that the staff member had been transferred from another home belonging to the same organisation and agreed to obtain the required information. There was evidence that the required CRB disclosure had been applied for. The inspector informed the manager that the staff member concerned must only work under supervision and not attend to residents on his own. The staff records examined indicated that staff had been provided with essential training and were knowledgeable regarding their role and responsibilities. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 19 One relative and a staff member were unhappy with the staffing arrangements in the home. The staff member stated that certain senior staff did not always assist junior carers while the relative stated that there had been insufficient staff. A further requirement is therefore made for the staffing arrangements to be reviewed with relatives and staff. The manager informed the inspector that effort had been made to transfer residents with high needs to other homes to ensure that the workload is manageable. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 20 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, 38 Staff and residents interviewed were of the opinion that the home was generally well managed. The manager was knowledgeable regarding his role and responsibilities. Arrangements were in place to ensure the health and safety of residents and staff. However, further improvements are needed. EVIDENCE: Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 21 The manager was noted to be knowledgeable and staff and residents interviewed expressed confidence in him. There was evidence that residents and relatives had been consulted regarding the management of the home and their preferences responded to. Window restrictors were fitted and these were engaged. Weekly fire alarm checks, fire drills and fire training had been documented. The inspector noted that no fire drills had been organised after dark. This is required to ensure that staff are fully aware of the required procedures to follow. The inspector noted that one of the fire doors on the first floor was defective as it did not close properly. This was brought to the attention of the manager who immediately contacted the maintenance department and arranged for work to be carried out. Documented evidence that he had made the necessary arrangements was provided to the inspector at the end of this inspection. The home did not have a comprehensive record of weekly health and safety checks. This is required for health and safety reasons and to ensure that call bells and emergency lighting are working, fire doors and exits are in working order and any safety hazards are identified and promptly minimised. The home had been inspected by the fire authorities (LFEPA) in July 2004 and within the past 2 months, but no report had yet been received or documented evidence to indicate that the fire safety arrangements were satisfactory. The registered person must therefore request for a fire safety inspection of the premises by the fire authorities (LFEPA)) to be carried out and forward a copy of the report when received, together with details of any action to be taken in response to requirements made. The home’s record of accidents was examined. These indicated that there had been an increase in the incidence of falls in the past month. The manager explained that this was because one of the residents was susceptible to falls.He reassured the inspector that this resident was now subject to constant close supervision. This was confirmed by an agency carer (providing close supervision) who was interviewed by the inspector. Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 22 Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 23 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 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 2 Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 24 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 7 Regulation 13(1)(b) Requirement The registered person must ensure that the chiropody needs of residents are attended to. The registered person must ensure that the temperature of the room where medication is stored is no higher than 25 C. (This requirement is restated) The registered person must ensure that the complaint brought to his attention during this inspection is fully investigated. A report regarding the outcome must be forwarded to the inspector. The registered person must arrange for safety inspections to be carried out by a qualified professional on -all the portable electrical appliances -the gas installations and - the hoists and assisted baths Evidence that these have been done must be forwarded to the Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 25 Timescale for action 27/11/05 2 9 13(2) 13/11/05 3 16 22(3) 13/11/05 4 19 23(2) 01/12/05 inspector . 5. 27 18(1)(a) The registered person must review staffing levels (and the manner in which staff are deployed ) with service users, relatives and staff to ensure that the needs of residents are met. A report of this review must be forwarded to the inspector. The registered person must ensure that all the staff records contain satisfactory CRB disclosures. The registered person must ensure that the staff member who has not yet received a satisfactory CRB disclosure is only allowed to work under supervision. The registered person must arrange for fire drills to be organised at least once every three months. One of these must be carried out after dark. The registered person must ensure that weekly health and safety checks are carried out. The registered person must request that an inspection be carried out by the LFEPA. A copy of the report together with details of any action taken must be forwarded to the CSCI. 13/12/05 6 29 19 01/12/05 7 29 19 13/12/05 8 38 23(4) 13/12/05 9 38 13(4) 01/12/05 10 38 23(4) 01/12/05 Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 26 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 Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 27 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 Rosetrees DS0000010523.V251156.R01.S.doc Version 5.0 Page 28 - 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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