Inspection on 14/12/06 for Beis Pinchos Nursing Home

This inspection was carried out on 14th December 2006.

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

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

Other inspections for this house

Beis Pinchos Nursing Home 14/11/07

Beis Pinchos Nursing Home 12/04/07

Beis Pinchos Nursing Home 23/01/06

Beis Pinchos Nursing Home 07/06/05

Beis Pinchos Nursing Home 30/11/04

Beis Pinchos Nursing Home 08/06/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beis Pinchos Nursing Home 2 Schonfeld Square London N16 0QQ Lead Inspector Robert Sobotka Unannounced Inspection 14th December 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beis Pinchos Nursing Home DS0000007351.V322817.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. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beis Pinchos Nursing Home Address 2 Schonfeld Square London N16 0QQ 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) 020 8802 7477 020 8809 7000 info@aihaltd.co.uk Agudas Israel Housing Association Eileen Gabb Care Home 43 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (35) of places Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Minimum Staffing Notice Four (4) named service users under the age of 65 years to be accommodated in the home, including one (1) service user with learning disability needs. Up to 35 Beds for Nursing Care Date of last inspection 23rd January 2006 Brief Description of the Service: Beis Pinchos Nursing Home provides specialist care services for older people from the Orthodox Jewish Community. The complex of Schonfeld Square is owned by Agudas Israel Housing Association and is a purpose built property. Beis Pinchos is a dually registered care home for 43 older people including 20 places for people with dementia and up to 35 service users with nursing needs. The home is based in the London Borough of Hackney on the border of Stoke Newington and Stamford Hill. It is in the midst of the largest Orthodox Jewish Community in Europe. Schonfeld Square is easily accessible by public transport and several parks and is near shops selling kosher food. Beis Pinchos offers a wide range of religious and culturally appropriate services and activities to both service users and the well-established Orthodox Jewish Community in the immediate area. The home takes referrals from throughout the UK and abroad and is currently operating the waiting list. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and was unannounced. The purpose of this visit was to check the home’s compliance with the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations. As part of this visit, the inspector spoke to a number of service users, staff working in the home. The registered manager was off on the day of this inspection, so the inspector spent some time with the Chief Executive, Mrs Ita Symmons, and the home deputy manager. In addition, he conducted a tour of the premises and reviewed a number of documents maintained by the home. The inspector would like to that everyone who took part in this inspection. What the service does well: The home provides a very good quality of care to those accommodated in the Being Pinchos Nursing Home. Those service users who spoke to the inspector expressed their satisfaction with the way they were cared for and conditions of the premises. The nursing and other healthcare needs of those accommodated in the home were being appropriately addressed. At the time of this inspection the home provided services to 19 service users with dementia and the inspector was satisfied that their assessed needs were being met. Staff working in the home were observed treating service users with dignity and respect and each person received highly personalised treatment in the home. The home continues to have a very high number of staff on each shift, as well as a large number of volunteers from the local Orthodox Jewish Community, who offered additional support in the home, such as supporting service users with activities, supporting service users with feeding during mealtimes and enabling service users in meeting their cultural needs. All staff working in the home were aware of Jewish customs and religious practices. The home provides a very wide range of activities on offer, as well as an excellent choice of meals to the service users. All meals offered in the home were Kosher. The home is commended for its quality assurance systems. The premises were well maintained. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 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 Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to have appropriate admission system in place and all service users were appropriately assessed by the registered manager prior to moving into the home. The needs of those service users who were offered intermediate care were also appropriately met. EVIDENCE: The home had an up-to-date Statement of Purpose and the Service User’s Guide in place. Both documents contained useful information about the home and services offered. During the course of this visit, the inspector checked care plans of two service users, who have moved in to the home since the last inspection. The inspector was satisfied that each person was appropriately assessed by the registered manager prior to offering a placement in the home. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 9 The home had an exemption to accommodate four named service users under the age of 65, including one service user with learning disability needs. This did not reflect the situation in the home at the time of this visit. The registered person must ensure that an application is made to the Commission to accurately reflect the number, ages and categories of service users accommodated in the home. Potential service users and their relatives are given an opportunity to visit and assess the quality, facilities and suitability of the home. At the time of this inspection, there were no vacancies in the home and the home was operating a waiting list. The home appropriately meets assessed needs of those service users who required intermediate care. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a good care planning system in place and all assessed needs of those accommodated in the home were appropriately met. Medication systems were well maintained. EVIDENCE: Each service user living in the home had a care plan. The inspector viewed 4 individual service users care plans, which were chosen at random. All care plans viewed were well written and contained comprehensive information in relation to each service user. Each care plan also described how each person’s needs would be met. There was evidence that care plans were reviewed on a monthly basis, or more often if required, and that service users and/or their relatives were involved in the care planning process. Since the last inspection, the registered manager has introduced a new dementia care plan. Work has also started in producing a life story for each person accommodated in the home. Care plans viewed listed actions needed by care staff to ensure that all healthcare, social, cultural and personal needs of each service user and there was evidence that views of each service users and or/their relative were taken Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 11 into account. The registered manager has also insured that each care plan contained a photograph of a service user, as previously requested. Each care plan viewed contained appropriate risk assessment, including moving and handling assessments. Since the last inspection, the home has introduced a system, where on each service users door there is a “dot” system, which enables staff working in the home to easily identify as to how many carers are required to undertake moving and handling with a service user. The home had appropriate nursing equipment in place. All service users were registered with a General Practitioner, who visited each person on a weekly basis. Those living in the home were also able to access any specialist healthcare facilities, when required. Good accident/incident recording systems were in place. There was also evidence that the registered manager carried out a periodic (yearly) evaluation to monitor and reduce a number of falls and any other incidents and accidents. The analysis of accidents gives a brief idea of how many accidents have occurred and it shows the time of day and place where an accident took place, so that a number of accidents/incidents in the home can be reduced/minimised. The home employs a high number of nurses. At the time of this inspection the home employed 8 nurses and 3 nurses were in the process of completing their nursing adaptation. There were always at least 2 nurses on duty during daytime and 1 nurse on duty during nights. There is also a nurse on-call at all times, which could be summoned in case of emergency. In addition the home has introduced a system where there is a senior carer on each shift. Both the registered manager and the deputy manager are also qualified nurses. As part of this visit, the inspector spoke to 2 of the nurses (excluding the deputy manager), who confirmed that they were happy working in the home and that they were provided with additional training to further develop and enhance their knowledge of clinical practices. A number of nurses have worked in the home for a number of years and those who spoke to the inspector said that they had no intention of leaving their current employment. Satisfactory medication systems were in place. All medication is kept in a medication room. Only registered nurses are authorised to administer prescribed medication to the service user and one nurse was in charge of carrying out regular medication audits. At the time of this inspection, the home was in the process of installing new medication cabinets in the medication room. The inspector checked a random selection of medication kept in the home. Records of medication brought into the care home, administered to service users, and disposed of was maintained. Medication stocks (including controlled drugs) were checked and found correct at the time of this inspection visit. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 12 The inspector spoke to several service users as part of this inspection. Those spoken to gave very positive comments about the way the home is run. They said that the Chief Executive, the home management and all staff working in the home were very approachable, friendly and they always had time to listen to service users. Service users also felt that they were treated with utmost dignity and respect. There was a very friendly and relaxed, yet professional atmosphere in the home. The death of a service user is handled according to Jewish Law. Staff have received training in palliative care to ensure that service users receive appropriate attention and pain relief. Staff have also attended lecture on cancer. Relatives are able to stay with service users for as long as they wish. The home has got a morgue at the rear of the garden. Beis Pinchos Nursing Home DS0000007351.V322817.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. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home continues to provide an excellent range of activities. Those living in the home are supported to exercise choice and to take control over their lives. Service users enjoyed food provided in the home. EVIDENCE: The home continues to provide a very broad range of activities to those living in Beis Pinchos. There is a very large number of volunteers from the local community who facilitated some of the activities. Each service user had a lifelong learning document in place. The home has a minibus, which is used for outings. Activities programmes are given out each Sunday for the forthcoming week to each service user. They are also displayed throughout the house. Activities usually start at 10.15am and finish at around 9pm. There were also specialised activities for people with dementia. On the day of the inspection, there was a choir performance from a local school and service users were encouraged to participate in singing along. Members from the local community also support service users in attending daily prayers in the home’s Synagogue. At the time of this inspection, the home was preparing for Chanukah Holidays. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 14 Maintenance of family involvement in very much part of the Jewish ethos of the home. The Chief Executive stated that whilst there were no restrictions on visits from the relatives and friends of the service users during most of the day, some restrictions have been imposed during mealtimes, as the sheer volume of visitors when service users were having meals had become unmanageable and meant that service users could not enjoy their meals in peace. In addition, due to the nature of referrals, more and more service users required support with feeding and high numbers of visitors meant that there was no room for carers to support service users. Most service users’ finances are handled by their relatives, which is traditionally accepted. Service users are encouraged to bring their own possessions, as agreed on admission to the home. Those who lived in the home had access to their records, in accordance with the Data Protection Act. All meals provided by the home are Kosher and cooked to meet traditional Jewish cuisine. The kitchen conforms to the Jewish Laws. The inspector joined service users for lunch. Food served was well presented, nutritious and tasty. Choice of food offered to service users for lunch on the day of this inspection included: barley soup, chicken soup, turkey stir fry, roast chicken, boiled chicken, pasta, eggs to individual request, mashed potatoes, spinach, sweetcorn, ice cream, fresh fruit salad, apple compote and prunes. Similarly extensive menu was on offer for supper. Individual requests are collected from each service user each day, should they change their mind and request other food, this is accommodated. Any other requests and special diets are catered for. Menus are provided in large print. Kitchen staff are supplied with a list of service users’ birthdays, so that they can prepare birthday cakes and meals for special occasions. Although communal dining is encouraged, room service was offered to those who preferred to eat in their own company. Separate eating arrangements are also offered to those service users, who have dementia and/or require additional support with feeding. Beis Pinchos Nursing Home DS0000007351.V322817.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a good complaints system in place. Service users were protected from abuse. EVIDENCE: The home continues to have a good complaints system in place. There have been two complaints about the home since the last inspection, both of which have been promptly resolved. There was a written evidence to show that all complaints were acknowledged and that the registered manager and/or the proprietor resolved them without delay. Staff spoken to stated that they would support service users in raising complaints on their behalf. The home had an appropriate protection policy and staff working in the home were aware of adult protection issues and have received relevant training. There was evidence that adult protection issues were also discussed during staff meetings, as well as during staff induction and supervision sessions. In addition, the proprietor visits the home on a daily basis and spends a lot of time with service user, when those who live in the home may bring any concerns and complaints. Record of accidents and incidents were appropriately maintained and monitored by the registered manager. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 16 As previously managed, most of the service user’s money is managed by their families. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users continue to benefit from a homely, comfortable, safe and clean environment. EVIDENCE: The premises are situated in the heart of Stoke Newington. The home is situated in Schonfeld Square, which is purpose built and has won some architectural awards. Service user bedrooms are located on three floors. All bedrooms have en-suite facilities and are similar in design. There are 3 quiet lounges and a larger lounge on the ground floor, where most of the activities take place. There is also a synagogue. Work has started on building an additional synagogue at the rear of the building, which will also contain day centre for activities. The premises were well maintained. The third floor accommodates 8 service users with dementia. Since the last inspection, the home has applied to the Commission for the permission to accommodate up to 20 service users with dementia, which was granted. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 18 All communal areas were spacious. The main lounge is used for a variety of specific cultural, social and religious activities and there are three lounges where service users can meet relatives. Lighting in communal areas is sufficiently bright and positioned to facilitate reading and other activities. During the tour of the premises, the inspector viewed a number of bedrooms on each floor, which were chosen at random. All bedrooms have en-suite facilities and an additional sink unit housed behind the cupboard doors. There are 6 communal bathrooms, one with a Parker bath, which is one the first floor. All bathrooms viewed were clean, tidy and hygienic. The premises were pleasantly decorated and the flooring was in good condition. The home had an adequate provision of aids and adaptations in place to assist those with physical disabilities. The home has a lift, grab rails in corridors and communal areas. There are call alarm systems in all rooms. Alarm system and the lift are serviced on regular basis. The majority of rooms had nursing beds. All bedrooms had a bed, a built-in wardrobe and a further wardrobe, a chest of drawers and a table and chair. All bedroom doors were kept closed and were lockable. Since the last inspection, the pictures of the service users have been placed on their bedroom doors to enable them to find their rooms more easily. Rooms viewed by the inspector were clean and in good decorative order. Service users who spoke to the inspector said that they were happy with their rooms and other parts of the building. Appropriate laundry facilities were in place. The premises were clean and hygienic at the time of this inspection. Appropriate clinical waste disposal arrangement and sluicing facilities were also in place. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and well-trained staff. The home’s recruitment practices must be improved without any further delay. EVIDENCE: Service users are supported and cared for by members of staff who are well trained and appropriately supported. The quality of care in the home continues to be of a very high standard. There are high staffing levels in the home at all times. As previously mentioned, there are always at least two registered nurses on duty, in addition to a nurse on-call, who is available in case of emergency. Since the last inspection, the home has implemented a system of senior carers with one senior carer being on duty at all times. The home employs a high number of care assistants, many of whom have relevant professional qualifications. Service users also benefit from a large number of volunteers, who spend time with service users every day. Throughout the visit, the inspector received positive comments about the management team and staff working in the home. Staff recruitment and gathering of all required documentation in respect of staff employed in the home is carried out by the Chief Executive and the Human Resources Department based in the Organisation’s head office and is not directly a responsibility of the registered manager. As part of this Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 20 inspection visit, the inspector reviewed some of the staff personnel files. The inspector is concerned that the requirement in relation to staff recruitment remains unmet. Although some progress has been made to meet the previous requirement, further work is required to ensure that the standard is fully met. Non-compliance with the Regulations may place service users at risk. Further non-compliance may result in the Commission considering the enforcement action against the provider. Staff working in the home told the inspector that the training offered to them was very good. The majority of staff working in the home have obtained NVQ (National Vocational Qualification) Level 2 and further funding has been obtained to provide NVQ training to other care staff working in the home. According to the Statement of Purpose, the home employed 58 staff members in departments of caring, nursing, catering, gardening, maintenance and domestic at various degrees of experience and qualifications ranging from RGN, PhD, BSc to NVQ Level 2 and 3. The inspector was satisfied that all staff working in the home (this included nursing, care and domestic staff) receive very comprehensive training. The management of the home are committed to an ongoing training and development. All new staff receive a comprehensive induction programme based on the TOPPS induction programme, which is also combined with am induction on religious observances and Orthodox Jewish laws and customs. The registered manager signs off each induction pack once it’s been completed with a new member of staff. The inspector interviewed 3 members of staff in private. They all shared the same opinion that the welfare and wellbeing on the service users was the main objective of the home. They all also said that the “service users always came first”. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 21 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, 32, 33, 34, 36, 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home continues to be managed to a very high standard with the service users’ interests and needs treated as a priority. Very good quality assurance systems were in place. Health and safety was maintained. EVIDENCE: The registered manager was not present on the day of this inspection and as a result Standard 31 was not fully assessed. Following the review of documentation, discussions with the service users and staff working in the home and based on previous inspections, the inspector was satisfied that the home was appropriately managed. The inspector was informed that the registered manager had obtained the NVQ Registered Managers Awards, as required by law. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 22 There continues to be high staff morale in the home and those working in the home are committed to providing a very high quality of care to those accommodated in the home. There was a positive, open and inclusive atmosphere in the home. There was a good quality assurance system in place. The Chief Executive visited the home nearly every day. Monthly unannounced visits were also taking place in line with Regulation 26 of the Care Homes Regulations. Following each visit the responsible person produces very thorough reports, which were available for inspection. The responsible individual ensures that the views of those living in the home and staff working there are obtained. As previously mentioned, the registered manager carried out a periodic (yearly) evaluation to monitor and reduce a number of falls and any other incidents and accidents. Service user questionnaires are distributed on a quarterly basis. Comments obtained are then analysed by the home management and implemented. The home was appropriately insured for its purpose. All members of staff were appropriately supported and received annual appraisals. Team meetings were held on regular basis and minutes from these were available for inspection. Staff spoken to said that they felt well supported by the management team. Appropriate health and safety checks were in place. Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 23 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 3 x 2 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 3 x 3 x 3 Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 24 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 OP29 Regulation 7, 9, 19 Requirement The organisation must ensure that all information listed in Schedule 2 of the Care Homes Regulations is maintained and that staff are only employed once all the necessary checks have been carried out. (Previous timescale of 01/03/06 was not met.) The registered person must ensure that an application is made to the Commission to accurately reflect the number, ages and categories of service users accommodated in the home. Timescale for action 01/03/07 2. OP3 14(1) 15/01/07 Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 25 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 Beis Pinchos Nursing Home DS0000007351.V322817.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. 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