Inspection on 18/04/06 for Rosetrees

This inspection was carried out on 18th April 2006.

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

The inspector found 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 11/10/05

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 Key Unannounced Inspection 18th April 2006 09:35 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.V287685.R01.S.doc Version 5.1 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.V287685.R01.S.doc Version 5.1 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 Mr Amos Samasuwo 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.V287685.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th October 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. The home 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 and are accessible to service users. The home is located in a private road off Colney Hatch Lane which is located close to local shops, public transport and other community services along Friern Barnet Road. The fee charged by the home is £706. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 18 April 2006 and took a total of 3 and a half hours to complete. The inspector found that many of the National Minimum Standards had been met and the overall quality of care provided was good. The inspector was accompanied by the deputy manager of the home (Ruby King). The inspector was able to interview five residents. The feedback received from them was positive and indicated that they were satisfied with the care provided. The visiting community nurse was interviewed. She indicated that the healthcare needs of her patients had been attended to. 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 (based at Lady Sarah Cohen House), kitchen and communal areas were inspected. Three staff on duty were interviewed on a range of topics associated with their work. In addition, the minutes of residents’ and staff meetings were examined. (The staff records were not available for inspection as they were kept locked by the manager.) What the service does well: The home was clean, modern and well furnished. Residents were observed to be clean and appropriately dressed. Staff were knowledgeable regarding their roles and responsibilities. The home had a comprehensive programme of social and therapeutic activities which were appropriate and met the physical, cultural and spiritual needs of residents. Meetings had been held for residents and relatives. There was evidence that their preferences had been noted and responded to. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 6 There was documented evidence that staff had been instructed by their manager to treat residents with respect and dignity. What has improved since the last inspection? 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. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 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 Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 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, 4, 6 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The deputy manager and her staff had a good understanding of the needs of residents and were able to ensure that their needs were met. The inspector was informed by the manager that the home does not provide intermediate care EVIDENCE: The inspector interviewed five residents. The feedback received from all was positive. They indicated that they were generally well cared for and staff treated them with respect. Comments made by them included, “nice staff ”, “staff are polite”, and “staff are helpful and responsive”. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 9 A sample of five residents’ case records which was examined contained detailed assessments, 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.V287685.R01.S.doc Version 5.1 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 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There was evidence that residents had been well treated and arrangements were in place to ensure that their healthcare, personal, cultural and social needs 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: The five residents interviewed, indicated that their healthcare needs had been attended to. Comments made included, “have seen the doctor” and “my medication had been given to me”. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 11 The sample of five case records examined were up to date and plans of care had been regularly reviewed. Records of medical and healthcare treatment were documented. A record of weekly GP visits had been maintained. The visiting community nurse who was interviewed indicated that there was close liaison with the home and her instructions had been attended to. She further confirmed that one of the residents who is diabetic had been given insulin injections by her and these were recorded. The temperature of the room (on the ground floor) where medication was stored had been recorded daily. This was not always satisfactory as there were occasions when 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 two of the residents’ case records did not contain documented evidence that they had been attended to by a chiropodist. This was discussed with the deputy manager and the previous requirement regarding access to chiropody services is restated. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 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 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The daily life and routines of residents were well organised. This ensured that the dietary, cultural and social preferences of residents are met. 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 planned for residents. The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. The kitchen in the home was inspected and found to be clean. The inspector noted that not all relatives and residents were satisfied with the arrangements for the provision of meals (as noted in the minutes of meetings and in interviews with residents). However, there was evidence that the home Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 13 manager and catering contractors were in the process of responding to concerns expressed. Residents interviewed were able to confirm that they had been visited by their relatives. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 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, 18 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements in place for responding to complaints and abuse were satisfactory. This ensures that the rights of residents are protected and they are treated with respect and dignity. 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. No complaints or allegations of abuse were received by the inspector. There was documented evidence that staff had been instructed by their manager to treat residents with respect. This was documented in the minutes of staff meetings. Staff interviewed were knowledgeable regarding the adult protection procedures. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 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, 20, 21, 22, 23, 24, 25, 26 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home was well equipped, clean and furnished to a high standard, therefore providing a nice environment to live in. Improvements are however, required in the area of health and safety. EVIDENCE: The premises were inspected and found to be clean and well furnished. The gardens were attractive and seating had been provided. Safety inspection certificates were seen by the inspector. These included the safety inspection certificates for the portable appliances and gas installations. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 16 There was evidence of safety inspections being carried out on the hoist and assisted baths. The inspector was not provided with evidence of a safety inspection being carried out on the electrical installations. For safety reasons, this is needed. The required certificate of inspection must be forwarded to the inspector. The inspector noted that the waste bag for paper waste and the mop and bucket used were placed on the same trolley as clean linen. This trolley was in use during the inspection. A risk assessment must be carried out regarding this arrangement to ensure that bedlinen is not contaminated. The laundry (based at Lady Sarah Cohen House) was inspected and bedlinen which had been laundered were examined. These were found to be clean and neatly folded. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 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, 30 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing and recruitment arrangements in place were satisfactory. This ensures that residents’ care needs are met. EVIDENCE: The five residents who were interviewed stated that staff were respectful towards them and they were generally satisfied with the care provided.. The duty rota was examined. In addition to the manager, there were ten care staff on duty during the morning shift and nine during the afternoon shift and five during the night shift. No concerns were expressed by either staff or residents regarding staffing levels. Four staff who were on duty were interviewed on a range of topics associated with their work (such as adult protection, fire procedures and the general care of residents). They were noted to be knowledgeable regarding their roles and responsibilities. The recruitment records examined (after the inspection) were found to be satisfactory and CRB disclosures had been obtained for staff recruited. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 18 Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 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, 34, 35, 38 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Health and safety arrangements were in place and residents and their representatives had been consulted. This ensure that the home is run in the best interest of residents. However, further improvements are needed. EVIDENCE: Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 20 The deputy manager was noted to be knowledgeable and staff and residents interviewed were of the opinion that the home was well managed. There was evidence that residents and relatives had been consulted regarding the management of the home and their preferences responded to. This was noted in the minutes of meetings examined. Window restrictors were fitted and these were engaged. Weekly fire alarm checks, fire drills and fire training had been documented. The inspector noted that a fire drill had been organised after dark. The inspector was not provided with 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. An immediate requirement was issued for this to be done (Evidence of compliance was provided after the inspection). The home had been inspected by the fire authorities (LFEPA), but no report had yet been received. Following a requirement made in the last inspection report, there was documented evidence that the registered person had made a request for a copy of the report to be provided. A current certificate of insurance was not displayed. An immediate requirement was made for this to be obtained (Evidence of appropriate insurance was provided following the inspection). Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 21 The fire risk assessment had not been updated. An immediate requirement was made for this to be done. Staff and residents interviewed were of the opinion that the home was well managed. The manager had however, not yet obtained his NVQ L4 qualifications. The inspector was informed by the manager (after the inspection) that he is in the process of completing his NVQ L4 studies. The home had an appropriate and current certificate of insurance. The financial records of residents which were examined were noted to be well maintained. Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 22 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 4 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 2 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 2 3 3 2 X X X 2 Rosetrees DS0000010523.V287685.R01.S.doc Version 5.1 Page 23 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 OP9 Regulation 13(2) Requirement The registered person must ensure that medication in the home is stored in an area or areas where the temperature can be maintained at 25 C or below. This requirement is restated. The previous unmet timescale was 13/11/05 The registered person must ensure that the chiropody needs of residents are attended to. This requirement is restated. The previous unmet timescale was 27/11/05 The registered person must carry 21/05/06 out a risk assessment regarding the use of the linen trolley for transporting the mop and brush and paper waste to ensure that bedlinen is not contaminated. The registered person must 20/06/06 arrange for the electrical installations of the home to be inspected by a qualified professional. Evidence that these have been DS0000010523.V287685.R01.S.doc Version 5.1 Page 24 Timescale for action 01/06/06 2 OP8 13(1)(b) 20/06/06 3 OP26 13(4) 4 OP19 23(2) Rosetrees 5 OP38 13(4) done must be forwarded to the inspector. The registered person must ensure that weekly health and safety checks are carried out. (evidence of compliance was provided after the inspection) The registered person must update the home’s fire risk assessment. (evidence of compliance was provided after the inspection) The registered person must provide evidence of appropriate insurance. (evidence of compliance was provided after the inspection) The registered manager must obtain NVQ L4 qualifications in management and care (or it’s equivalent). 24/04/06 6 OP38 23(4) 17/05/06 7 OP34 25(2)(e) 25/04/06 8 OP31 9(2)(b)(i) 01/09/06 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.V287685.R01.S.doc Version 5.1 Page 25 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.V287685.R01.S.doc Version 5.1 Page 26 - 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!