Inspection on 09/01/07 for Lady Sarah Cohen House

This inspection was carried out on 9th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 17/01/06

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 Key Unannounced Inspection 9th January 2007 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.V322952.R01.S.doc Version 5.2 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.V322952.R01.S.doc Version 5.2 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.V322952.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 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 residents with dignity and respect and enabling them to lead 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. The fees charged by the home range from £731 to £1058. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 9 January 2007. The inspection took a total of four and a half hours to complete. The inspector noted that the quality of care provided at the home was of a high standard. During this inspection, the inspector was assisted by the home manager (Mr Ernest Tsang). The inspector was able to interview four residents. The feedback received from them indicated that they were satisfied with the care provided. Seven completed questionnaires received from residents and their representatives indicated that they were satisfied with the care provided. Statutory records were examined. These included four residents’ case records, the maintenance records, accident records, complaints’ record and fire records of the home. The premises including residents’ bedrooms, treatment room, communal rooms, laundry, bathrooms and kitchen were inspected. Five staff on duty were interviewed on a range of topics associated with their work. Staff records were examined. These included supervision and training records. The minutes of meetings with relatives were also examined. What the service does well: The feedback received from residents and their representatives indicated that staff were highly thought of and they were satisfied with the care and management of the home. Residents interviewed stated that they had been treated with respect and dignity. Residents had access to a varied and comprehensive range of social and therapeutic activities. A complementary therapy room was available for the use of residents. Staff and residents / their representatives had been consulted regarding the management of the home. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 Page 6 The supervision and staffing arrangements were found to be satisfactory and staff were knowledgeable regarding the care of residents with dementia. The home had a low turnover of staff. The premises were clean and well furnished. Effort had been made to make it homely. What has improved since the last inspection? What they could do better: Improvements are required in the area of Health & Safety and maintenance of the home. The registered person must arrange for the emergency lighting to be checked / tested at weekly intervals or in accordance with the manufacturers’s instructions. Fire alarm tests must be carried out weekly. Fire drills must be organised at least once every three months. One of these must be carried out after dark. The kitchen floor must be kept dry and any leakage of water must be promptly drained away. Maintenance deficiencies identified (leak in a resident’s bedroom and lamp that was not working) must be rectified. Improvements are also required in the care arrangements. Comprehensive care plans which address the assessed needs of residents must be provided. These must include a dementia care plan and pressure area care plan for the service users identified. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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 Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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. 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. Arrangements were in place to ensure that residents’ aspirations and needs are assessed. This ensures that their needs can be identified and met at the home. EVIDENCE: The inspector experienced some difficulty interviewing residents because of their mental condition. However, three residents who were able to express their views indicated that their care needs had been met at the home and they were satisfied with the care provided. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 Page 10 Comments made by them included, “well treated” and “they take good care of me”. Completed questionnaires received from residents and their representatives indicated that they were satisfied with the care provided. Comments made included, I know my wife is in good and caring hands, and my husband is well looked after. Residents had been assessed prior to admission. Four residents’ case records which were examined, contained comprehensive assessments. Risk assessments together with strategies for minimising risks had been prepared. The inspector observed that residents in the home were clean, appropriately dressed and appeared well cared for. The inspector was informed by the manager that the home does not provide intermediate care Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 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. Residents had been well treated and arrangements were in place to ensure that their healthcare and personal needs are attended to. Further improvements are required in the care plans of residents. EVIDENCE: The three residents interviewed, indicated that their healthcare needs had been met. The sample of four 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 GP visits and medication reviewed had been maintained. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 Page 12 The home had a procedure for combating dehydration. The manager stated that jugs of water had been provided in bedrooms. Monitoring forms for personal care provided were used in the home. These had been completed. Residents interviewed were able to confirm that they had been given their medication. The MAR charts were appropriately signed. Temperatures of the fridge and room where medication was stored had been monitored daily. These were satisfactory. The records of a resident with diabetes were examined in detail. The inspector noted that appropriate monitoring of the resident and appropriate care had been provided. The records of a resident with a Waterlow score which indicated a high pressure sore risk did not contain an appropriate pressure area care plan. This is required to ensure that the identified risk is minimised. The records of a resident with dementia did not contain a dementia care plan. This is required to ensure that the appropriate care is provided. Requirements are made accordingly. Residents interviewed, indicated that they had been treated with respect. This was confirmed in completed questionnaires received. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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. 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 on the whole, well organised. This ensured that the dietary, cultural and social preferences of residents are met. EVIDENCE: The inspector discussed the provision of activities with the manager. He was informed that the home had a varied programme of weekly social and therapeutic activities. The daily programme was on display outside the office. Activities provided included art, music & movement, sensory sessions, games, quiz and gentle exercise. Residents interviewed were of the opinion that the activities were appropriate. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 Page 14 The home had a complementary therapy room where residents could receive aromatherapy, hand massage, music and light therapy. The activities manager stated that this had benefited certain residents. Residents who were interviewed informed the inspector that they had been visited by their relatives. The bedrooms inspected had been personalised by residents with their personal items such as photos and souvenirs. The kitchen was clean and well equipped. Residents interviewed indicated that they were satisfied with the meals provided. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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. 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 for responding to complaints and for adult protection were satisfactory. This ensures that residents are well treated and protected from abuse. EVIDENCE: The complaints record was examined. No complaints were recorded. The manager explained that none had been received. Staff interviewed were aware of the procedure to be followed when responding to allegations of abuse. Staff had been provided with adult protection training. Residents who were interviewed indicated that they had been well treated by staff. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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. 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 good. 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. Further improvements are however, required. EVIDENCE: The premises were inspected and found to be clean and well furnished. All bedrooms had ensuite facilities. Fridges and telephones were available in bedrooms inspected. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 Page 17 The gardens were attractive and seating had been provided. There was a fountain at one corner of the garden. The laundry was inspected. Bedlinen which had been laundered were noted to be clean. Residents who were interviewed stated that they were happy with the accommodation provided. Safety inspections had been carried out on the portable appliances, hoist, gas installations and electrical installations. The inspector noted that there was a small pool of water in the main kitchen (near the drain and to the right of the main entrance as you enter from the catering office). The chef in charge explained that this was due to drainage problems experienced. Prompt action was taken and the matter was rectified. For safety reasons, a requirement is nevertheless made for the kitchen floor to be kept dry (except when it is being cleaned). A lamp in one of the bedrooms was not working. A leak was noted in a resident’s bathroom. Requirements are made for these to be attended to. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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. 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 arrangements were on the whole, satisfactory, thus ensuring that residents were well cared for by staff. Further training updates in the care of residents with diabetes are needed. EVIDENCE: Staff who were on duty were interviewed on a range of topics associated with their work (such as fire procedures, adult protection procedures, staffing arrangements). 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 eleven staff on duty during the day shift (including three nurses) and five staff (including two nurses) during the night shift. The manager was supernumerary. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 Page 19 Staff indicated that the staffing levels were adequate. The inspector noted that new 12 hour shifts had recently been introduced. This was discussed with staff. No complaints regarding this staffing arrangement were made. The staff records examined indicated that the required recruitment standards and procedures (including obtaining satisfactory CRB disclosures and references) had been followed. At least 50 of care staff had NVQ L2 qualifications. The inspector noted that some nursing staff had not been provided with updates on the care of residents with diabetes. This is required to ensure that staff are fully informed. A requirement is made accordingly. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 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 home was run in the best interest of residents and arrangements were in place to ensure the safety and welfare of residents in the home. Further improvements are required in the area of health & safety. EVIDENCE: The manager is a qualified nurse and he provided documented evidence that he had obtained the required management qualifications. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 Page 21 The inspector was provided with evidence that residents’ representatives are consulted as part of the home’s quality assurance monitoring. The minutes of these meetings were available for inspection. These had been held every two months. The home had a valid certificate of insurance. Staff interviewed informed the inspector that they had been provided with regular supervision sessions. Documented evidence was available for inspection. The minutes of staff meetings were available for inspection. The fire records examined contained details of fire drills, fire training and weekly fire alarm checks carried out. Fire exits were kept clear. The home had an updated fire risk assessment. Fire alarm checks had been carried out. However, these had not always been done weekly. To ensure that any defect in the alarm is promptly noted and rectified, the fire alarm must be tested weekly. The manager responded promptly and the fire alarm was checked prior to the second visit to the home. Only two fire drills had been organised in the past year. A minimum of four drills are required (one of these must be carried out after dark). These drills are needed to ensure that those in the home are aware of action to be taken in the event of a fire. The manager responded promptly and a fire drill (after dark) was organised. The financial records of residents were examined. These were well maintained. A recent quality audit of the home was provided. This was positive and indicated that the home was well managed. Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 4 3 3 4 4 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 3 3 3 3 2 Lady Sarah Cohen House DS0000010494.V322952.R01.S.doc Version 5.2 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 OP7 Regulation 13(1) 14(1) 15(1) Requirement The registered person must provide comprehensive care plans which address the assessed needs of service users (this must include a dementia care plan and pressure area care plan for the service users identified ). The registered person must ensure that the kitchen floor is kept dry and any leakage of water is promptly drained away. The registered person must ensure that the maintenance deficiencies identified (leak in a resident’s bedroom and lamp that was not working) are rectified. The registered person must ensure that nursing staff are provided with training updates in the care of residents with diabetes. The registered person must arrange for the emergency lighting to be checked / tested at weekly intervals or in accordance with the manufacturers’s instructions. DS0000010494.V322952.R01.S.doc Timescale for action 21/02/07 2 OP19 13(4)(c) 23(2)(b) (c) 13(4)(c) 23(2)(b) (c) 13/02/07 3 OP19 13/02/07 4 OP30 18(1)(i) 13/04/07 5 OP38 13(4) 23(2)(a) (b)(c) 21/02/07 Lady Sarah Cohen House Version 5.2 Page 24 6 7 OP38 OP38 23(4) 23(4) The registered person must 14/02/07 ensure that fire alarm tests are carried out weekly. The registered person must 14/02/07 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) 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.V322952.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V322952.R01.S.doc Version 5.2 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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