Inspection on 01/08/05 for Lady Sarah Cohen House

This inspection was carried out on 1st August 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

Lady Sarah Cohen House 05/01/09

Lady Sarah Cohen House 09/01/07

Lady Sarah Cohen House 17/01/06

Lady Sarah Cohen House 05/01/05

Lady Sarah Cohen House 16/08/04

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 Lady Sarah Cohen House 1st Floor Asher Loftus Way Colney Hatch Lane London N11 3ND Lead Inspector Daniel Lim Unannounced 1 August 2005 @ 12.35 pm 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 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. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Lady Sarah Cohen House - 1st Floor Address Asher Loftus Way, Colney Hatch Lane, London N11 3ND Telephone number Fax number Email 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 8920 4400 020 8920 4414 Simon Morris for Jewish Care Ernest Tsang N Care Home with Nursing 40 beds Category(ies) of OP Old Age registration, with number DE(E) Dementia over 65 of places Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5 January 2005 Brief Description of the Service: Lady Sarah Cohen House is a purpose built hotel style care home, for older jewish people. The home opened in October 1997 and is operated by Jewish Care. The home is a large four storey, detached building. On the ground floor is located the kitchen, laundry, coffee shop and synagogue. The hydrotherapy pool, reception area, clerical and administrative offices are also on this floor. The first floor of Lady Sarah Cohen House is registered to provide nursing care for a maximum of forty older people who have dementia. The aims of the home are to create a homely, relaxed environment with emphasis on treating users with dignity and respect and enabling users to leading a full and active life. The home is situated at the end of a private road (Asher Loftus Way) which leads away from the busy Colney Hatch Lane. It is a short distance from the North Circular Road. It is well served by a variety of shops, restaurants and other community services located along Friern Barnet Road. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 1 August 2005 and took a total of 3 hours to complete. The inspector found that most of the National Minimum Standards had been met and the overall quality of care provided was of a high standard. During this inspection, the inspector was accompanied by the manager of the home (Mr. Ernest Tsang). The inspector was able to interview two residents and two relatives. The feedback received from them indicated that they were satisfied with the care provided. The inspector attempted to interview four other residents, but they were unable to comment on the care provided due to their dementia. Completed questionnaires were also received from relatives and a social services staff. These indicated that residents were well cared for. Statutory records including four residents’ case records, the maintenance records and fire records of the home were examined. The premises including bedrooms, laundry, kitchen, gardens and communal areas were inspected. Staff on duty were interviewed on a range of topics associated with their work and staff records were examined. In addition, the minutes of staff meetings were also examined. What the service does well: Residents and relatives interviewed were fully satisfied with the care provided and spoke highly of staff. This was reflected in completed questionnaires received. The home was modern, well equipped and furnished to a high standard. The home had benefited from stable management and many of the staff had worked there for several years and were knowledgeable of the needs of residents. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 6 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. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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 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 are met. EVIDENCE: Two residents who were interviewed stated that they were well cared for and staff were caring towards them. This was confirmed by two relatives interviewed. Comments made by them included, “excellent care provided”, “couldn’t find a better home” and “wonderful staff”. Completed questionnaires received from relatives indicated that the respondents were satisfied with the care provided at the home and the needs of residents had been met. A sample of four residents’ case records which were examined contained comprehensive plans of care and details of how residents needs had been met. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 10 The inspector observed that residents in the home were clean, appropriately dressed and appeared well cared for. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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 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. Some improvements are however, needed in the administration of medication. EVIDENCE: Feedback from residents and the two relatives interviewed, indicated that residents’ healthcare needs had been met. Comments made included, “can see the doctor when required” and “medication given by staff”. The sample of four case records examined were up to date and plans of care had been reviewed. Records of medical and healthcare treatment were documented. Staff interviewed were knowledgeable regarding the care to be provided to residents. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 12 The temperature of the room where medication was stored had been recorded daily and was satisfactory. However, the temperatures of the fridge where medication was stored was not recorded daily. This is required to evidence that they are maintained between 2-8oC. It was noted that one of the MAR charts had not been correctly signed (or filled in with the correct symbol) to indicate when medication was not administered. This must be done. Requirements have been made in this report for the identified deficiencies to be rectified. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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 standard(s) 12,13,15 The daily life and routines of residents were well organised and met the cultural and social preferences of residents. Residents and relatives indicated that they were happy with the meals served. However, improvements are needed in the kitchen. EVIDENCE: The inspector noted that the home had a varied programme of weekly social and therapeutic activities for residents. During this inspection a music session was organised for residents. Residents and relatives who were interviewed indicated that they were satisfied with the activities provided. The two residents who were interviewed stated that they had been visited by their families and friends. The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 14 The kitchen and arrangements for the provision of meals were examined. The inspector noted that the lino in the kitchen was split in two areas. These must be repaired. In addition, the carpet outside the dry store was stained and not kept clean. This area must be kept clean. Consideration should be given to replacing it with a floor covering which is more easier to clean. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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 standard(s) 16, 18 There was evidence that the rights of residents were protected and complaints were taken seriously. This protected residents from abuse and ensured that any complaints they had were listened to and acted upon. EVIDENCE: The complaints record was examined. There was documented evidence that complaints recorded had been promptly responded to. Residents and relatives who were interviewed stated that residents had been well treated. Comments made about staff included, “kind and helpful staff”, “they treat residents with respect” and “caring, cheerful staff” . Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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 standard(s) 19,20,21,23,24,25,26 The home was well furnished and well equipped, therefore providing a pleasant environment to live in. EVIDENCE: The premises were inspected and found to be generally 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. The communal areas were well furnished and appeared cosy. The required maintenance records and safety certificates were seen by the inspector. These included safety inspection certificates for the gas installations and fire safety equipment. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 17 The laundry was inspected and staff interviewed were aware of the need to wash soiled and infected laundry at a temperature of at least 68C for at least 10 minutes. Linen and clothes which had been washed were examined. These were found to be clean and neatly folded. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The recruitment process in place ensured that residents needs were met by an appropriate group of staff. Further staff training is required in adult protection and staffing levels must be reviewed. EVIDENCE: Staff who were on duty were interviewed on a range of topics associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. Relatives who were interviewed stated that staff were professional in their approach and respectful towards them and the residents. Some staff stated that the staffing levels were not always adequate in the afternoons and they were not able to spend sufficient time with residents. This was discussed with the manager and a requirement is made for staffing levels to be reviewed again The training records examined, indicated that staff had been provided with most of the essential training required. However, some staff had not received training on adult protection. This is required to ensure that staff are fully informed of action to be taken when responding to allegations of abuse. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 19 Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,38 Systems were in place to ensure that the rights and interests of residents were safeguarded. However, improvements are needed in the area of health and safety. EVIDENCE: When interviewed on a range of topics associated with the care of residents and staff management, the manager was found to be knowledgeable. Residents and staff interviewed expressed confidence in the manager. All relatives interviewed spoke highly of staff and were of the opinion that the home was well managed and residents were receiving a high standard of care. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 21 The fire logbook examined indicated that fire drills and weekly checks of the fire alarm had been carried out. Fire training had been arranged for staff. When questioned, staff were knowledgeable regarding the fire procedures. The inspector however, noted that no fire drills had been organised after dark (dusk). This is required to ensure that staff are aware of the required procedure to follow. The home did not have a comprehensive record of weekly health and safety checks. This is required to ensure that call bells are working, fire doors and exits are clear and any safety hazards are identified and promptly minimised. Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x 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 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 3 3 x 3 4 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 4 3 x x x x 2 Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 23 no Are there any outstanding requirements from the last inspection? 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 9 Regulation 13(2) Requirement The registered person must ensure that the temperature of the medication fridge is maintained between 2 - 8 C The registered person must ensure that MAR charts are correctly filled in and the appropriate symbols are used. The registered person must ensure that the split lino in the main kitchen of Lady Sarah Cohen House is repaired. The registered person must ensure that the corridor between the dry store and the kitchen is kept clean. The registered person must review staffing levels and and undertake any actions identified out of the review so as to ensure it has sufficient staff to meet the needs of residents throughout the afternoon. A report of actions undertaken following this review must be forwarded to the inspector. The registered person must ensure that all staff are provided with training on adult protection. The registered person must arrange for fire drills to be Timescale for action 1/9/05 2. 9 13(2) 1/9/05 3. 19 23(2) 30/10/05 4. 26 23(2)(d) 1/9/05 5. 27 18(1)(a) 3/9/05 6. 7. 30 38 13(6) 23(4) 30/10/05 20/9/05 Page 24 Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 8. 38 13(4) organised at least once every three months. One of these must be carried out after dark. The registered person must 1/9/05 ensure that weekly health and safety checks are carried out and documented. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 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 Lady Sarah Cohen House 1st Floor G59 S10494 Lady Sarah Cohen House 1st Floor V240410 01.08.05 Stage 4.doc Version 1.40 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. 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