Inspection on 12/08/08 for Beth Ezra Trust

This is the latest available inspection report for this service, carried out on 12th August 2008.

CSCI found this care home to be providing an Excellent service.

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

Beth Ezra Trust 08/12/05

Beth Ezra Trust 02/09/05

Beth Ezra Trust 11/03/05

Beth Ezra Trust 13/01/05

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 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Beth Ezra Trust Beth Ezra Home 52 Smitham Bottom Lane Purley Surrey CR8 3DB Lead Inspector David Pennells Unannounced Inspection 12th August 2008 10:05a 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 Beth Ezra Trust DS0000019023.V369032.R02.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. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beth Ezra Trust Address Beth Ezra Home 52 Smitham Bottom Lane Purley Surrey CR8 3DB 020 8668 7116 020 8668 1084 bethezra@tiscali.co.uk 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) Beth Ezra Trust Janet Brooks Care Home 18 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (18) of places Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on the 30th August 2006, one named service user with dementia can be accommodated. The CSCI must be informed when this service user no longer resides at the home. 6th July 2006 Date of last inspection Brief Description of the Service: Beth Ezra is owned and managed by the Beth Ezra Trust - a Christadelphian Community charity. The home is registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to eighteen adults over the age of sixty-five. The service does not accommodate people with nursing needs, unless they can be provided by district nursing services. Staffing is predominantly provided by non-Christadephians, but all are clearly in sympathy with the homes objectives and Statement of Purpose. A large but homely environment, accommodation consists of fourteen single and two double bedrooms, located over two floors. There is a large open plan lounge / dining area on the ground floor. The service encourages the people who use the service to remain independent and to enjoy the facilities provided. A copy of the service’s Statement of Purpose and Service User Guide can be obtained on request from the Registered Manager. There have been no changes in the ownership / management or service registration details in the last 12 months. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. We undertook this inspection on 12th August 2008 from just after 10.00am to about 5.30pm. We met with the manager of the home - Janet Brooks, and conducted a substantial tour of the premises; staff members were interviewed, as well as the people who live at Beth Ezra - and relatives of a few people were also met during the visit. Records relating to all aspects of the home’s operation were looked at. We made observations of care practices, and we sampled the food - the inspector joining those in the dining room for lunch. We received the views, in writing - of four relatives, three care workers and six people living at Beth Ezra - via questionnaires handed out and posted back to us; the views of these people - in the main, very positive and appreciative are actively reported in this report. The manager also provided comprehensive information about the home in the Annual Quality Assurance Assessment document required by us. The inspection process closed following receipt of these important questionnaires and the AQAA. What the service does well: This is a well run home where service users have there needs well met. There are good arrangements for ensuring that people’s needs are assessed prior to them moving into the home, and they and their representatives are consulted with about the care to be provided on an ongoing basis. People have their spiritual, social and health needs met well. People are protected by good practice in handling of medication and a good care planning process is in place. Arrangements for the handling complaints and allegations of abuse are good. There are good arrangements for ensuring that people using the service live a fulfilling lifestyle, in accordance with their wishes - and where appropriate following their chosen spiritual pathway. Structured activities are provided daily (including the daily Bible Reading at 4.00pm) and there are opportunities and space for people to relax and spend time with their family members and friends. The home is comfortable, very clean, and well maintained. The grounds of the home offer an expansive and pleasant space to enjoy and relax. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 6 Staff members are supplied in adequate numbers, and there is good staff training provided. All staff members are thoroughly vetted, offering a good level of protection to service users. Health and safety is taken seriously. Staff training continues to be well provided, with over 78 of the care staff being NVQ qualified, and the support services team now also commencing NVQ training. Induction training has also been sophisticated in the recent past. There is good management of the home, and an excellent quality assurance system - independently run by a ‘QA Group’ that takes into account the views of all those using the service. A regular visit by a member of the Board of Trustees is also a further mechanism to ensure best practice. The service continues to let us know about things that have happened since our last key inspection and Annual Service Review, and they have shown that they manage issues arising well. The organisation continues to work well with the Commission, and this inspection has shown us that the service continues to provide good outcomes for the people who use it. The three requirements set at the last inspection visit have been addressed, and the care planning and reviews process have developed. Catering remains an in-house service, whilst laundry and cleaning is contracted out. Relatives recently told us they were very happy with the service provided and that their loved-ones were happy with their decisions to move into the home. One relative told us: “It [the home] is absolutely brilliant, and, with the help of inspection, is always ready to better something that is already excellent…” What has improved since the last inspection? What they could do better: Four recommendations are made, two relating to continuing to develop the care planning documentation (one relating to ‘tidying up’ the paperwork, and one relating to adopting the first person singular in expressing care plans in a person-centred way). Following a mention in questionnaires from staff relating to slippery floor surfaces in en-suites, the floor surfacing should be reviewed. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 7 A final recommendation suggests that the CSCI model format should be considered for the Regulation 26 visits of the ‘Person in Control’ - as the whole process of these visits is currently under review. 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. Beth Ezra Trust DS0000019023.V369032.R02.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 Beth Ezra Trust DS0000019023.V369032.R02.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. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. There are appropriate arrangements and pre-admission processes for obtaining information about the needs of a person before they move into the home which allows for these specific needs to be addressed and met. This is a user-focused service with people at the home their relatives / friends fully participating in the process of planning for their care and monitoring their changing needs, this ensuring that the wellbeing of service users is promoted and protected. The home does not provide intermediate care. EVIDENCE: The home receives referrals predominantly through private arrangements (though five people are placed by local authorities - London Borough of Croydon, West Sussex and Kent Social Services), so the assessment by the Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 10 home is critical. Assessment information seen for recent admissions included a short social history, risk assessments and details about the service user’s personal and health care needs. Documentation also evidenced that the people using the service - and some family members - are involved in this process. One person has been admitted to the home with a diagnosis of dementia, this being agreed with us by a registration condition for the home. Beth Ezra is otherwise not registered to provide care specifically for people who have a diagnosis of dementia - and does not currently intend to adopt this specialism though the Registered Manager is confident that the home can continue to currently meet the needs of the person to whom the variation applies. Inevitably, some people living at the home develop some signs of the condition -and the home supports people only to the point where they feel they ca maintain a good quality of life for that person and the others around them. All staff members have received training with regard to understanding dementia and appropriate care practice. Relatives have reported that they felt that enough information is provided by the home to help in decision-making at the point of admission and introduction to the service. One person met by the inspector who had moved in recently stated that she was very satisfied by the welcome and attention to detail that had been given throughout this process. They mentioned how useful it was to come into the home for a while and then return home - only to realise that they would prefer the long-term support of Beth Ezra more - so then ‘came back’ to the care home with a more positive and proactive approach. Excellent feedback from people living at the home, and their relatives, was given about the service provided in general. The service does not provide an intermediate care service, so this standard does not apply. Beth Ezra Trust DS0000019023.V369032.R02.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 - 11 People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. There are good arrangements for ensuring that service users have their health, social and personal care needs well met, with good documentation available to ensure that all staff members are clear about how they should address service user’s need. There are good arrangements for ensuring that medication is handled safely and a strong emphasis is placed on protecting the dignity, and respecting the privacy of service users. This ensures that the well being of service users is protected. End of life care is sensitively and carefully handled, ensuring respect and dignity to the end of a resident’s life. EVIDENCE: Care plans for a number of people using the service were examined. They were up-to-date and had been regularly reviewed. Plans contained information Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 12 about the service user’s personal, spiritual, health and social care needs - and there were risk assessments in relation to moving & handling and pressure area care. The manager explained that the service is moving towards a more person-centred approach to care planning - this approach puts the person at the centre of all the work undertaken. We recommend that plans are therefore written in the first person singular in future - to help express the personal wishes / individual approach of such a process. Staff confirmed that they are thoroughly briefed when coming on to shift with a thorough update relating to individual care plans. Care records showed that people have access to a range of community health care professionals, and that the home is proactive in arranging health care appointments. Records detailed that people are generally registered with a local general practitioner, and have their weight monitored regularly, seeing other professionals such as opticians and dentists as necessary. Policies and procedures in place to ensure that medication is handled safely; Medication Administration Records seen were accurately kept and up to date. Staff confirmed that they had received training in the safe handling of medication, and there was a written record detailing all staff members who had received such training. Medication is stored securely and there are facilities available for handling ‘controlled’ medication. Some people are encouraged to maintain responsibility for their own medication administration. The Registered Manager confirmed that the home continues to receive good support from the pharmacist and that regular audits of the medication system occur. Staff members were observed at all times to treat people at the home with respect and to uphold their dignity. Staff members knocked, and waited for a response, before entering someone’s bedroom. End of Life care is evidently an important element for those at Beth Ezra - and this facet was borne out by the intense care being provided for one person who was close to death at the time of the visit. Care was being provided in liaison with district nursing services. Extra staffing was being provided on shifts to support the staff team through this time. The home aims to support the person and the relatives / friends throughout this time - in a pastorally sensitive way. Feedback from relatives has confirmed that this care is ‘excellent’. The quality assurance survey found that all respondents stated there were always staff members available to them if they needed assistance throughout the day and the night. Staff members were described as ‘very kind’ and ‘very friendly’. Relatives and carers were universally happy with staffing attitudes and input. All those who use the service and responded to the quality assurance questionnaire stated that the staff knew what their needs were and how to respond to them. Some staff expressed the desire to see more staffing provided - explaining this would enhance the 1:1 focus of care provided. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 13 Most relatives interviewed by the quality assurance group knew who their loved one’s keyworker was, and also had participated / contributed to their care planning (some relatives chose not to be involved). There was an identified need to continue to explain to everyone the roles and purposes of keyworkers and care planning as a concept. Families and friends indicated in their feedback to us that they were kept informed of things affecting their friend/ relative. With regard to personal care, a respondent stated: “they exceed expectation the care and support must be the best in the land.” Another commented: “Staff all seem dedicated beyond the call of duty.” Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 14 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 - 15. People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s lifestyles in the home continue to be varied - with an attractive activities programme seeking to express individual’s social, cultural and spiritual backgrounds, and a positive welcome is given to relatives, friends and visitors, ensuring active and ongoing engagement with skills and interests. Wholesome and enjoyable meals - responding to choice and preferences are provided - in a pleasant and warm environment; this encouraging a balanced diet and the positive benefits from nutritional wellbeing. EVIDENCE: People clearly continue to have good opportunities for social and recreational activity and engagement. The activities programme displayed in the lounge showed that a group activity was programmed for the morning sessions and that there would be daily Bible readings at 4.00pm in the afternoon. People spoken with said that they enjoyed the range of activities and recreational facilities available to them, a marked number speaking of how important it is to ‘keep the grey matter working’. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 15 A new TV and Video player have been bought to further enhance the use of purposeful and positive activity for people at the home. A hairdresser is available and works in the home on a regular basis. A physiotherapist also visits the home on a regular basis, this being funded by the home. About five people were engaged in a quiz / reminiscence session on the morning of our visit (which then became the topic of conversation at lunchtime), and the Bible Reading was enjoyed by a good majority of people living at the home - whether Christadelphian or not - and all involved were enjoying both these activities. People enjoyed going on arranged outings, which were regularly arranged, to the coast, countryside, or garden centres. A good number of visitors / relatives were seen visiting the house during the inspection visit. People generally have good opportunities to be involved in decision making in the home. There are regular Residents’ Meeting, facilitated by staff members, with opportunities to formally decide about day-to-day life in the home. Decision-making is also encouraged through the Quality Assurance Group, which reports annually. Staff in the lounge were noted to consult people about all aspects of participation / activity. Staff also consulted people at lunchtime about what meal they would like, and what portion size. The pudding trolley especially provoking a lot of interest and decision-making! The published menu detailed meals that are varied, and a choice is always available. Fresh, wholesome and nutritious food was available in the kitchen. The kitchen was - as ever - very clean and well organised, and all staff members undertake food hygiene training. Certificates were noted for staff members who work in the kitchen. A meal was sampled during this inspection. This was very tasty, well presented and enjoyable. There was (as ever) a very large selection of different deserts. The attention paid to providing a wide range of attractively present deserts - in order to encourage service users to eat well - is seen as good practice. Hot and cold drinks are provided throughout the day, at the end of lunchtime at the table or in the lounge, and on request. All people at the inspector’s table said that meals in the home were enjoyable and of invariable good quality. One said, “The food is always well-cooked, hot and presented….” Another confirmed: “They are good - they always ask you what you want.” Another stated in writing: “The salads and fresh fruit are SUPER.” Specialist diets are catered for; in catering for a service user who requires a liquidised diet, the food was very attractively served on a plate in different coloured portions - to ensure that the variety of flavours could be savoured. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 16 With this excellent approach to providing individualised portions, this Standard reverts to an ‘excellent’ rating. Staff members assist people with eating difficulties in a discrete way. There continues to be very good arrangements for ensuring that service users eat well. Relatives reported that the home always supports their friend / relative to live the life they choose. One said: “There is always such a lovely atmosphere” another also recognised the “friendly atmosphere with personal care”. Another mentioned that the house is “always fresh and clean and the personal care is of the highest quality.” The quality assurance survey found that all those interviewed stated they enjoyed the activities and recreations provided. The garden and the ‘mentally challenging’ quizzes were popular, as were the videos shown and also the Bible Readings. With regard to food at the home, the survey found, again, that all surveyed enjoyed the food provided. Choices were acknowledged, and the quality and variety of food was satisfactory, though some did feel that this could be improved further. Relatives and carers who had partaken of meals at the house were fulsome in their praise - as was the inspector on the day of the visit who shared an excellent lunch with a group of people in the dining room. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 17 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. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. A well-documented and publicised system effectively handles complaints and concerns expressed by people using the service and their relatives. All are encouraged to highlight concerns they may have. People can be confident that their concerns will be noted and acted upon. Arrangements are in place for recognising and handling allegations of instances of abuse. This ensures that service users will be protected from harm. EVIDENCE: There is a clear updated policy and procedure in place for dealing with complaints and concerns. Information is made available in the Service User Guide about how a complaint, concern or suggestion should be made, and how this will be handled. People at the home and their relatives are encouraged to raise any concerns with staff members before they become problematic. No specific complaints have been made about the home since the last inspection. People using the service indicated they knew how to make a complaint. The home has a copy of Croydon Council’s (the ‘host borough’s) Vulnerable Adult Protection / Safeguarding Policy and Procedures. Records are kept of staff members who have undergone training in PoVA / Safeguarding. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 18 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, 23, 25 & 26. People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is maintained, decorated and furnished to a very high standard and facilities are clean and kept safe. This ensures that service users live in a pleasant, homely and comfortable environment. EVIDENCE: The home is well maintained and provides an extremely pleasant, safe and homely environment to those who live there. There are large, very well maintained gardens to the rear of the property, offering a number of sheltered seating areas, and there are ramps providing access for wheelchair users. One person said they had a special ‘oasis’ in the garden, where they went to say their prayers. Some people at the home have been involved in the creation and maintenance of raised flowerbeds. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 19 There is adequate parking available at the front of the building - which is predominantly laid to tarmac. Building work undertaken in the past few months has refurbished two bedrooms, which are now to a higher standard than before, providing wheelchair access to the ensuite toilets, and having new furniture and soft furnishings. Previous refurbishment projects have also improved bedrooms which now ensures that all rooms at Beth Ezra comply with National Minimum Standard space requirements, and have en-suite facilities. Following up a comment by staff to the CSCI questionnaire, it is recommended that an examination of flooring in individual ensuite facilities is carried out, as staff suggest some could be slippery, and hence present a hazard. People are encouraged to personalise their bedrooms with their own ornaments, pictures, photographs and some furniture. People individually stated that they liked their bedroom - each is individual in size and shape - and many enjoy a view of the fine back garden. A number of window frames / panes at the front of the building have been replaced with aesthetically correct triple glazed units - providing improved insulation against the poor weather, and reducing noise levels from the increasingly-used Smitham Bottom Lane outside. All areas of the home seen were clean and free from malodours. A person living at the home wrote: “Very clean - excellent.” The laundry facilities are compact but suitable and there are policies and procedures for the control of infection. A dedicated laundry person has evident pride in their work. A new ecological-friendly boiler has been installed in a new location, this resulting in an enhanced stabilised heating effect for the entire home. Maintenance and servicing records were kept for all aspects of the home’s equipment and were well documented. The home is committed to improving / refurbishing the large and well-used ground floor bathroom. There are also plans to install a new ‘rise and fall’ transfer bathing unit. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 20 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 - 30. People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Staff members are provided in sufficient numbers and the procedures for the recruitment of staff are robust and provide the safeguards to offer protection and safe handling / treatment to the people living in the home. There is a good staff training and development programme that provides staff members with skills necessary for meeting the needs of service users. EVIDENCE: Staffing levels are maintained to an adequate level and generally meet the needs of people living at the home, in line with the care planned needs of current service users at the home. The Team Leaders support care staff members, and the Team Leaders are supported by the Registered Manager. Known ‘bank’ staff members are used to cover vacant hours - this ensuring that familiar faces are provided to people at the home at all times, without recourse to external agency workers. An in-house employed cook, and a laundry person and domestic staff are provided, supervised by the maintenance and services manager of Foxley Professional Services - the external domestic services provider. Feedback from staff members, people using the service and visitors generally thought that staffing levels were sufficient to meet everyday needs. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 21 Personnel files for new staff members were examined. These individual staff documents evidenced that all required checks had been carried out prior to the staff members commencing work in the home. One staff member expressed their frustration at the length of time their CRB clearance had taken. Records showed that new staff members had undergone a detailed induction programme with the Registered Manager being satisfied that the staff member had understood the information provided to them during induction. There were records detailing that the new staff members had read the home’s policies and procedures. Staff reported a high level of satisfaction with the induction processes undertaken by the home. There were records indicating that staff training has been ongoing since the last inspection. Team Leaders are being encouraged to complete the NVQ Level 3 in Care qualification. Of a total of twenty care staff working at the home (including ‘bank’ workers), twelve are currently qualified minimally to level 2 NVQ in care and a further five are undertaking the level 2 course; this will result in 82 of care staff being qualified to this level. All staff at the home have food hygiene training. All permanent staff members have undertaken distance-learning courses on dementia care. Support staff members are also being taken through courses at NVQ levels relevant to their work activity. Kitchen staff, though directly employed by the home, are supported and supervised by the manager of the external domestic and laundry staff; this ensures that health and safety aspects, training and monitoring are all brought under one ‘roof’ and has a seamless approach within the house. People living at the home reported: “very good staff attendance - always helpful” and “All the staff are very kind indeed and very patient, never say a cross word, nothing is too much for them.” / “They are very competent and know what they are doing - can’t speak too highly of them.” Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 22 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, 36 & 38. People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. There continues to be good management of the home and an excellent quality assurance system, which, alongside other consultation processes, ensures that the home is run in the best interests of service users. Health and safety is taken seriously, with staff well supervised, ensuring that the health and well being of service users is maintained and protected. EVIDENCE: There continues to be a well-qualified (RMA / NVQ at level 4 in management and Professional Development Certificate in Management and Care) - and experienced - Registered Manager in post - Janet Brooks. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 23 Staff members spoken with said that they received good support and guidance from her; Janet Brooks was described as “approachable and very ‘hands on’.” People living at Beth Ezra also clearly like and respect the manager, all having a positive regard for her, both as an individual and as the service’s manager. There is an annual development plan for the home and a number of tools for self-monitoring. The Quality Assurance Group survey - which reported in January 2008 - showed that the Survey Group adopted a clear plan of action and thorough consideration of the data collected was undertaken, before coming up with their three recommendations. The areas in question covered increasing awareness of the care planning system, of keyworkers, and of the complaints policy and process. The survey found that in almost all aspects, excepting knowledge of the complaints procedure, satisfaction levels had increased on the previous year’s survey. The QA Group Report was well presented and clear in its purpose and outcomes. This is a most commendable process and shows that Beth Ezra is actively seeking out ways to improve an already very good service. Regular monthly inspections are undertaken - to satisfy the Regulation 26 obligation of the registered provider - by one of the Trustees. It is suggested that the CSCI ‘model’ for these inspections could act as a template for future reports. This is accessible from the CSCI Professional website. There are records detailing that staff members are trained in safe working practices such as moving and handling, food hygiene, infection control and First Aid. All staff responding to the survey were able to report that they were meeting regularly with their manager to receive support and to discuss the working processes of the home. All staff members responding to the survey were clearly proud of the home, and keen to point up the positive service which is evident at Beth Ezra. Staff identified that “all the residents’ needs are individually catered for” / “we maintain a high level of service for our residents” / “we provide a peaceful environment for the people who use our service.” / “it’s a nice place to work”. Records seen show there are regular safety checks on water temperatures, fridge and freezer temperatures, the fire alarm, emergency lighting, fire fighting equipment, and ‘dorgards’. There are regular and well-documented fire drills, safety checks, gas and electricity checks, mains and portable electrical appliance safety checks - and testing for Legionella. There are risk assessments in place for chemicals and all accidents and incidents are recorded. The manager responded well to a suggestion that additional staff should be ‘trained up’ to cover basic health and safety checks when the maintenance person is occasionally absent from the home. Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 24 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 3 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 X X 3 X 3 3 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 3 X 4 X 3 3 X 3 Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations That care plans are filtered and those with multiple updates and changes be renewed - so that the current plan is most obvious and clearly presented to staff. That plans are therefore written in the first person singular in future - to help express the personal wishes / individual approach of such a process. Recommend examination of flooring in ensuite facilities, as staff suggest could be slippery. Recommend the CSCI website suggested model for Care Homes Regulation 26 visits by the person-in-control. 2. OP7 3. 4. OP25 OP33 Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Beth Ezra Trust DS0000019023.V369032.R02.S.doc Version 5.2 Page 27 - 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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