Inspection on 10/11/05 for Beenstock House

This inspection was carried out on 10th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beenstock House 13/02/09

Beenstock House 16/01/07

Beenstock House 05/02/06

Beenstock House 15/11/04

Beenstock House 17/08/04

Beenstock House 17/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beenstock House 19-21 Northumberland Street Salford Gtr Manchester M7 4RP Lead Inspector Helen Dempster Unannounced Inspection 10th November 2005 10:00 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 Beenstock House DS0000008355.V255806.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. Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beenstock House Address 19-21 Northumberland Street Salford Gtr Manchester M7 4RP 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) 0161 792 1515 0161 792 1616 Agudas Israel Housing Association Mrs Vered Begal Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2004 Brief Description of the Service: Beenstock is a residential home providing care for up to sixteen service users on a long term or short term respite arrangement. The home offers a culturally specific service for Orthodox Jewish people, in particular holocaust survivors. The home has been built with appropriate physical adaptations to suit this client group who have very specific cultural requirements. Referrals are received from the local community, other areas of Britain and from abroad. The home was first registered on the 18.08.99 and is owned by the Agudas Israel Housing Association and managed locally by Beenstock Home Management Company Ltd. The home is situated in a residential area of Salford and is located next to the local Synagogue. Ample car parking facilities are available, and well maintained gardens and patio areas surround the home. Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out on 10 November 2005 from 10.00am to 2.00pm. Time was spent talking with the Deputy Manager, staff and residents. This included discussing welfare matters relating to the residents the home supported and examining documentation in relation to the running of the home, the management arrangements, care planning and the residents’ satisfaction. The Manager was not on duty at the time of inspection and some documents, including staffing files, were not accessible to the Deputy Manager. Therefore standards relating to staffing and some other issues will be assessed at the next inspection. The term of address preferred by the users of the service was confirmed as ‘residents’. It was felt this best reflected the function and purpose of the service. What the service does well: What has improved since the last inspection? Medication practice at the home had improved since the last inspection. This included better recording, storage, ordering systems, key holding and staff training. Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 6 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. Beenstock House DS0000008355.V255806.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 Beenstock House DS0000008355.V255806.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): 1, 2, 3 and 6. Residents’ needs were assessed and documented. EVIDENCE: At the previous inspection, requirements were made to the effect that the home reviewed the Statement of Purpose and developed a Service Users Guide. A requirement was also made about the need to provide terms and conditions of service and contractual information on each service user’s file. The Deputy Manager was unable to locate these documents and the requirements were repeated. Some residents were admitted into the home with a social services needs assessment. The home also completes its own needs assessment. Wherever possible, the prospective resident was assessed by the manager at their own home, or in hospital, prior to admission. After the admission the home completes a “long term need assessment and care plan”. Examples of these were viewed and were found to be detailed. When prospective respite care residents were living abroad, information was gained regarding the individual’s needs by telephone and letter. The home does not offer intermediate care Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 9 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 and 10. Residents’ health, personal, social care needs and medication needs are documented and met and their rights are respected. One weakness was the lack of risk assessments, which had the potential to compromise residents’ safety. EVIDENCE: At the time of the inspection each resident had their own individual care plan. Overall, on the files viewed, these contained extensive information and detail as to how the resident required assistance with day-to-day support and delivery of personal care. Information regarding activities, visitors and medical needs was also in place. Care plans needed to be extended to include a care plan for the administration of medication, including ‘when required’ (PRN) medication, which confirms why medication is prescribed and in what circumstances and for what conditions PRN medication is given. A requirement made at the previous inspection to the effect that risk assessments must be in place for all aspects of daily living (which contain more detail to clarify staff intervention and state strategies to minimise risk) which must be subject to ongoing review had not been fully actioned and was Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 10 repeated. These must include a risk assessment for all residents concerning the risk of falls and for those residents who are self medicating. Medication practice at the home had been reviewed in response to requirements made by CSCI’s pharmacist inspector at the previous inspection. This included improving the recording of the receipt of medication into the home, the records of administered medication, the medication ordering system, the storage facilities for medication, the key holding arrangements, clarity regarding ‘as required’/’as needed’ medication, and training staff in basic medication handling. Those residents who expressed a view said that they were respected and that their right to privacy was respected. A resident’s relative said that she visits on a daily basis and has “never had a concern”, feels that the staff are “kind and caring” and that the care is “brilliant”. This is good practice. Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 11 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 and 15. Visiting arrangements were appropriate and residents’ recreational interests, health, cultural and dietary needs were all well met. EVIDENCE: The home has an open visiting policy and residents and visitors confirmed that the home welcomed visitors Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 12 Social interests and religious activities were recorded in the care plan, in posters in the hallway and in writing to each individual resident on a weekly basis in the appropriate language. This is good practice, which exceeds the standard. The home has visitors and volunteers from the local community visiting the home on a regular basis, who, if required could on occasion advocate on behalf of a resident if they so wished. However, as noted in a requirement at the previous inspection, the home did not have any information displayed regarding independent advocacy services that were available within the local community who could take on the role of representing individuals and the requirement was repeated accordingly. The home is next to a synagogue and this enables resident’s religious needs to be met through ease of access for residents through a path that runs from the home directly to the synagogue. The home had flexible mealtimes and the menu offered a varied, healthy, culturally appropriate and balanced diet with alternative choices. Residents said that the food was good. Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 13 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 and 18 A clear complaints procedure and record of complaints was available to allow residents to raise concerns. The “Protection of Adults from Abuse Policy” was not readily available which had the potential to compromise residents’ safety. EVIDENCE: The home had a complaints policy and procedure and record of the outcome of complaints. Salford Council’s Protection of Adults from Abuse Policy was not readily available at the time of inspection. The senior member of staff on duty was advised that it needed to be a working tool that all staff were familiar with and therefore needed to be readily available to staff at all times. A requirement was made accordingly Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 14 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): The environment was well maintained, clean, homely and attractive and was subject to ongoing improvement so that it consistently meets residents’ needs. EVIDENCE: A partial tour of the premises was conducted and the home was found to be clean, well maintained, homely and attractive. The handyman was at the home on the day of inspection and he said that he visits on a daily basis. Lounge and dining areas are spacious and comfortable. All bedrooms are single and those viewed were pleasantly decorated and contained residents’ personal effects. . Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 15 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. Sufficient numbers of well informed staff were meeting the residents’ needs and the use of volunteers from the community meant that residents were well supported. EVIDENCE: At the time of the inspection, there was sufficient staff on duty to meet the needs of residents. The use of volunteers from the community meant that residents were well supported and staff demonstrated a thorough knowledge of residents’ needs and wishes. . Shift patterns were organised to take into consideration the cultural/religious needs of the residents. A staff compliment of both Orthodox Jewish staff and non-Jewish staff were employed at the home. A requirement made at the previous inspection to the effect that there is separate allocated staffing for the residential home and for the domiciliary care service had not been actioned and has been repeated. The manager was not on duty at the time of inspection, which meant that information needed to assess whether requirements about staffing made at the previous inspection were met was not assessable. The requirements were therefore reiterated and the standards will be fully assessed at the next inspection. Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 16 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): 38 Overall, fire safety checks were consistently made. However, the safety of residents and staff could be compromised by the lack of an up to date fire risk assessment. EVIDENCE: At the time of inspection, fire safety checks were being undertaken and the outcomes recorded consistently. However, the home did not have an up to date fire risk assessment. An immediate requirement was made to the effect that the advice of the fire department must be sought on the completion of a fire risk assessment for the home. Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 17 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 X 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 4 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 18 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 Regulation Requirement Timescale for action 10/01/06 OP1 4 2 OP1 5 3 OP2 5 The registered person must produce and make available to residents an up to date Statement of Purpose, which includes all the information required by Regulation 4(1) and schedule 1 of the Care Homes Regulations. The registered person must 10/01/06 produce a Service Users Guide to the home for current and prospective resident, which includes all the information specified in standard 1. 10/01/06 Each resident must be provided with a statement of terms and Conditions at the point of moving into the home, which meets all aspects of standard 2. Risk assessments must be in place for all aspects of daily living. These must contain more detail to clarify staff intervention and state strategies to minimise risk and must be subject to ongoing review. Risk assessments must be in place and be subject to review DS0000008355.V255806.R01.S.doc 4 17 10/12/05 OP7 5 13 and 17 10/12/05 Beenstock House Version 5.0 Page 19 for all residents concerning the risk of falls and for those residents who are self medicating. 6 A care plan for the administration of medication, including when required” (PRN) medication, which confirms why medication is prescribed and in what circumstances and for what conditions PRN medication is given must be in place for each resident. The home must provide residents with information on advocacy and include details of advocacy services in the service users guide. Salford Council’s Protection of Adults from Abuse Policy must be readily available to staff at the home at all times. Staff must receive input and training to ensure increased awareness of abuse and knowledge of policies designed to safeguard residents. The management of the home is required to furnish the Commission with a staffing plan that demonstrates that there is separate allocated staffing for the residential home and the domiciliary care services. The registered person must complete a full audit of staff files to ensure that all documentation is included as detailed in schedule 2. A full audit of training and training plan must be completed to ensure that all staff have up 10/12/05 13 7 OP14 8 22 10/01/06 10/12/05 OP18 13 9 10/01/06 OP27 18 10 OP29 11 OP30 19 10/01/06 12 18 10/01/06 Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 20 to date mandatory training. 12 The registered person must formalise staff training and development and document the process. All new staff must complete induction to NTO specification within the first six weeks of appointment and all staff must receive three paid training days per year. Policies and procedures must be in place to ensure systems are in place to manage situations where it is necessary to manage service users finances. It is required that all records containing personal information are kept in as safe and secure environment. A full review and update of policies and procedures must be made. The home must obtain the advice of the Fire Department on the completion of a fire risk assessment, which details the risk from fire in the Beenstock Home. The responsible individual is required to contact Gtr Manchester Fire Service for up to date advice and guidance in relation to fire prevention and evacuation practices. 10/01/06 OP30 18 13 OP35 14 OP37 15 OP37 16 23 17 17 20 10/01/06 10/01/06 10/01/06 11/11/05 17 23 10/12/05 OP38 Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 21 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 Beenstock House DS0000008355.V255806.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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. 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