Inspection on 17/01/06 for Lady Sarah Cohen House

This inspection was carried out on 17th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lady Sarah Cohen House 05/01/09

Lady Sarah Cohen House 09/01/07

Lady Sarah Cohen House 01/08/05

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 Mental Nursing Home (1st Floor) Asher Loftus Way Colney Hatch Lane London N113ND Lead Inspector Daniel Lim Unannounced Inspection 17th January 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 Lady Sarah Cohen House DS0000010494.V269788.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. Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lady Sarah Cohen House Address Mental Nursing Home (1st Floor) Asher Loftus Way Colney Hatch Lane London N113ND 020 8920 4400 020 8920 4414 etsang@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 Ernest Kai-cheong Tsang Care Home 40 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 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 DS0000010494.V269788.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 17 January 2006 and took a total of 3 ½ 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 three residents and one relative. 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. The home’s GP who was visiting the home was also interviewed. He indicated that residents were well cared for their healthcare needs had been attended to. 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: The home was modern, well equipped and furnished to a high standard. Residents interviewed were generally satisfied with the care provided. The home had a comprehensive programme of daily activities and these had been carefully tailored to suit the needs of the client group. Individual social care plans had been prepared for residents which reflected their preferences. There was regular consultation with residents and their representatives. Staff were well trained and knowledgeable regarding their roles and responsibilities. Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lady Sarah Cohen House DS0000010494.V269788.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 Lady Sarah Cohen House DS0000010494.V269788.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, 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: The inspector was able to interview three residents and one relative. The feedback received from them indicated that they were satisfied with the care provided. Comments made by them included, “satisfied with care”, “staff help me when needed” and “staff respectful”. A sample of four residents’ case records which were 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. Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 9 Lady Sarah Cohen House DS0000010494.V269788.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 Residents had been treated with respect and arrangements were in place to ensure that their healthcare, personal, cultural and social needs are attended to. Some improvements are however, needed in the administration of medication. EVIDENCE: Feedback from home’s GP, residents and the relatives interviewed, indicated that residents’ healthcare needs had been met. Comments made included, “I have seen the doctor” and “medication given to me 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 (including chiropody) were documented. The record of doctor’s visits indicated that residents’ prescribed medication had been subject to review. Staff interviewed were knowledgeable regarding the care to be provided to residents. The temperatures of the room where medication was stored and the fridge for medication had been recorded daily and were satisfactory. Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 11 It was noted that one of the MAR charts had not been properly filled (the required pulse of the service user was not recorded prior to administration of a certain medication). To ensure that medication is correctly administered this must be done. The inspector further noted that a risk assessment had not been documented for a resident who was at risk of falls. This was brought to the attention of the manager and an assessment was provided before the end of the inspection. Lady Sarah Cohen House DS0000010494.V269788.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 The daily life and routines of residents were well organised and met the cultural and social preferences of residents. Residents were generally happy with the meals served. EVIDENCE: The home had an activities organiser and he was able to provide the inspector with a comprehensive programme of daily activities organised. These had been carefully tailored to suit the needs of the client group. Individual social care plans had been prepared for residents which reflect their preferences. Residents interviewed were of the opinion that the home had activities which were appropriate and which they were happy to join in. The inspector was also able to speak to the complimentary therapist and view the new therapy room. The therapist stated that residents had been provided with hand massage, music and light therapy and this had increased their alertness Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 13 The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. Lady Sarah Cohen House DS0000010494.V269788.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, 18 There was evidence that the rights of residents were protected and they had been well treated by staff. EVIDENCE: The complaints record was examined. There was documented evidence that the three complaints recorded since the last unannounced inspection had been promptly responded to. Residents and the relatives who were interviewed stated that they had been well treated by staff. Lady Sarah Cohen House DS0000010494.V269788.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, 20, 21, 22, 23, 24, 25, 26 The home was well furnished and well equipped, therefore providing a pleasant environment to live in. Some improvements are however, needed in the kitchen. EVIDENCE: The premises were inspected and found to be clean and well furnished. The premises had been refurbished. The manager explained that attention had been paid to ensuring that the environment is specially adapted for those with dementia. Two smaller lounges had been created. The manager stated that these provided a more cosy atmosphere. The hot water in bedrooms was tested and found to be within the required safe temperature range of no higher than 43 C. Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 16 The gardens were attractive and seating had been provided. The area under the stairs next to the reception was cluttered with excess furniture. This was brought to the attention of the receptionist and manager. These items were immediately cleared during the inspection. The home had safety inspection certificates for the gas installations. Bedlinen which had been laundered were examined These were found to be clean and neatly folded. The kitchen was inspected and it was noted that there was a split in the lino. The registered person must ensure that the split lino in the main kitchen of Lady Sarah Cohen House is repaired. Lady Sarah Cohen House DS0000010494.V269788.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, 30 Staff were well trained and knowledgeable. However, there is a need to review staffing arrangements. 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. Residents who were interviewed stated that staff were respectful and responsive towards them. The duty rota was examined. This indicated that there was normally ten staff on duty during the day shift (including two nurses) and five staff (including two nurses) during the night Some staff stated that the staffing levels were not always adequate in the mornings and they were not able to spend sufficient quality time with residents or complete care and medication documentation. This was discussed with the manager who was of the opinion that staffing levels were adequate. A requirement is therefore made for staffing levels to be reviewed again. The Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 18 inspector discussed the need for a senior manager to be present when staff are being consulted. Lady Sarah Cohen House DS0000010494.V269788.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, 34, 36, 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 and staff supervision. 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. Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 20 The relative and doctor 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. The fire logbook examined (on 9 Jan 06) 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 now had a comprehensive record of weekly health and safety checks (including checks on the fire doors). The inspector examined two staff records. It was noted that the two staff had been supervised. However, these were not done on a regular basis. A requirement is therefore made for this to be done. Lady Sarah Cohen House DS0000010494.V269788.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 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 2 X 2 Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 22 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) The registered person must ensure that MAR charts are fully completed (and this must include the pulse of the resident, if required. 2. OP19 23(2) The registered person must ensure that the split lino in the main kitchen of Lady Sarah Cohen House is repaired. (This requirement is restated) 3. OP27 18(1)(a) 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. 4. OP38 23(4) The registered person must Lady Sarah Cohen House DS0000010494.V269788.R01.S.doc Version 5.0 Page 23 Requirement Timescale for action 27/02/06 01/04/06 13/03/06 20/09/05 arrange for fire drills to be organised at least once every three months. One of these must be carried out after dark. (This requirement is restated) 5. OP36 18(2) The registered person must ensure that staff are provided with regular supervision (at least once every two months). 13/04/06 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 Lady Sarah Cohen House DS0000010494.V269788.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 Lady Sarah Cohen House DS0000010494.V269788.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. 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