Inspection on 02/09/05 for Beth Ezra Trust

This inspection was carried out on 2nd September 2005.

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 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 06/07/06

Beth Ezra Trust 08/12/05

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beth Ezra Trust Beth Ezra Home 52 Smitham Bottom Lane Purley, Surrey CR8 3DB Lead Inspector Diane Thackrah Unannounced 2 September 2005 09:30 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 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 G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beth Ezra Trust Address Beth Ezra Home, 52 Smitham Bottom Lane, Purley, Surrey, CR8 3DB Telephone number Fax number Email 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 8668 7116 020 8668 1084 Beth Ezra Trust Janet Brooks Care Home 18 Category(ies) of OP Old Age (18) registration, with number of places Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 11 March 2005 Brief Description of the Service: Beth Ezra is owned and managed by the Beth Ezra Trust, which is 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 anyone with nursing needs. Staffing is generally provided by non-Christadephians, but all are clearly in sympathy with the homes objectives and purpose. 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 service users to remain independent and to enjoy the facilities provided. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 2nd September 2005 between 11.20 and 14.30. A partial tour of the premises took place and care records were examined. The Registered Manager and three staff members were spoken with. Some service users were also spoken with, and these all expressed their satisfaction with the service. A large number of comment cards were received from both service users and their family members. All feedback received about the home was positive. What the service does well: What has improved since the last inspection? Since the last inspection, the majority of the staff team have undertaken training in recognising, preventing and reporting elder abuse. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 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. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 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 standard(s) 2, 3 and 4. The home continues to carry out assessments of needs for prospective service users so that service users can be assured that their needs will be met. EVIDENCE: Each service user is provided with a written statement of terms and conditions at the point of moving into the home. There was a signed contract in place for the most recent admission and this contained all information required by Regulation. New referrals to the home come via the Christadelphian community and all the service users currently residing at the home have links with the Christadelphian movement. Assessment documentation was examined for the most recent admission to the home. This included detailed information about the service user’s medical history and medication, diet, continence, social interests and hobbies and personal care needs. Additional information about the service user’s needs had been obtained from a care home from which they had been admitted. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 9 There is a key worker system in place that allows service users individual needs to be addressed. Staff members spoken with demonstrated a good awareness of the individual needs of service users. Discussions in a staff meeting focussed on the individual needs of each service user, and action needed to meet changing needs. All service users spoken with expressed their satisfaction with the home. One service user said that the staff were “very good” another service user said that staff members were “very helpful and will go out of their way to help you” Feedback received in comment cards indicated that service users needs are well met. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10. There are good arrangements for addressing the personal and health care needs of service users; this allows service user’s needs to be met and ensures their well-being. In general, service users are respected and have their dignity upheld. One incident was observed were a service user’s dignity and right to make a decision was not upheld. This is not in the best interests of service users, and compromises their well-being. EVIDENCE: Each service user has a care plan that is generated from a needs assessment. The care plans of three service users were examined. These had been drawn up with the involvement of the service user. There was detailed information in each care plan about the action needed to be taken by staff members to ensure that all aspects of the health, personal and care needs of service users are met. Daily observation records are maintained for each service users. These detailed that staff members follow guidelines detailed in care plans. Risk assessments are in place for each service user. These cover risks in relation memory, mental health, mobility, bathing and moving and handling. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 11 Records detail that care plans are reviewed on a regular basis and updated to reflect changing needs. Records indicate that staff members and community based health care professionals, including GP’s, dentists, opticians, and chiropodists closely monitor the health of service users. Weight charts, nutritional assessments and waterlow scores were available in personal files examined. All accidents and incidents in the home are recorded and monitored. Training in dignity, respect and confidentiality forms part of the induction training for all staff members. Care records indicate that service users are consulted about the care that they receive. Staff members were also observed to consult with service users at the time of this inspection. Feedback from service users was that they were treated with respect and had their dignity upheld and it was evident from discussion with one staff member, that they were aware of the need to respect privacy. However, one incident was observed were a service user’s dignity and right to make a choice was not upheld by a staff member. Staff members must treat service users with respect and uphold their dignity at all times. A recommendation is made in relation to this issue. A number of service users have had a private telephone line installed in their bedrooms. Screening is available for use in double bedrooms. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Social activities are well organised and provide stimulation for service users. Service users are given opportunities for exercising personal choice and therefore retain some control over their lives. Meals are nutritious and balanced and offer a healthy and varied diet for service users. EVIDENCE: There was a notice board in the home detailing that an exercise class would be held in the morning and a quiz would take place in the home afternoon. The Registered Manager said that activities are provided in accordance with the needs and wishes of service users. This view reflected feedback received from service users. Service users spoken with reported “I enjoy the prayer meetings” “I enjoy the garden” and “I like watching videos in my bedroom” One service user said, “We had a concert here recently which I liked” The home has a positive approach to visitors. Facilities are available for visitors to be seen in private, or in the communal area. One service user said that they regularly received visitors. Another said that staff members had been particularly supportive about them receiving visitors, and that they were being provided with a ‘special meal’ for an arranged visit from their family members. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 13 Feedback received from a number of service users was that they were able to exercise choice and control. Details about a forthcoming service user’s meeting were available on the service user’s notice board. This meeting had been arranged to allow service users to comment on a newly devised selfmedication policy. There is information available about local advocates. Service users are entitled to bring personal possessions with them, and many have done so. Access to personal records can be facilitated. Service user’s said that meals were enjoyable and that a choice was always offered. One service user said, “Meals are always very good” A meal of omelette, or fish, mashed potatoes and peas was being served for lunch at the time of this inspection. This meal was nutritious and was well presented. Most service users ate in a pleasant main dining room with attractively set tables; others ate in their bedrooms. The kitchen was well organised, clean and hygienic. All service users spoken with said that meals were very good, that a choice was always available and their individual preferences were always taken into account. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. There is a system in place for the effective handling of complaints and service users and their relatives are encouraged to raise any concerns they have. Service users therefore know that their concerns will be acted upon. Arrangements are in place for handling allegations and instances of abuse. This ensures that service users will be protected from harm. EVIDENCE: There are policies and procedures in place for dealing with complaints. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information also includes details about how a complaint may be made to the Commission for Social Care Inspection. The Registered Manager said that service users and their relatives are encouraged to raise any concerns with staff members before they become problematic. No complaints have been made about the home since the last inspection The home has a copy of Croydon Council’s vulnerable adult protection procedures. The Registered Manager assured the inspector that there have been no allegations of abuse made within the home in the past year. Since the last inspection of the home, sixteen members of the current staff team have undertaken training in recognising, preventing and reporting elder abuse. Records of this training were available for inspection. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 21, 24, 25 and 26. The home is decorated and furnished to a high standard and facilities are clean and safe. This ensures that service users live in a pleasant, homely and comfortable environment. EVIDENCE: There are toilet and bathing facilities on each floor on the home. These were noted to be clean and accessible. A specialist bath and showers is available. All bedrooms have an en suite toilet and sink. Sluicing facilities are situated separately from service user’s bathing and WC facilities. Bedrooms viewed were homely, comfortable and personalised. All service users spoken with expressed satisfaction with their bedrooms. Furniture is provided, or service users may bring their own furniture. Locks are provided on bedroom doors and lockable storage space is available in rooms. All baths and bedroom sinks have been individually fitted with preset, fail-safe and tamper proof thermostatic mixer valves to ensure the temperature of hot water used in these areas remains close to 43 degrees Celsius at all times. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 16 Regular checks are made of hot water temperatures. Bedrooms are naturally ventilated with windows conforming to recognise standards. There is central heating throughout the home, and radiators can be adjusted in individual bedrooms. Pipe work and radiators are covered and lighting is domestic in nature. Emergency lighting is provided throughout the home. All areas of the home were found to be very clean and hygienic. One service user said that their bedroom was kept very clean. The laundry is sited well away from the kitchen. There is a contract for the collection of clinical waste and the washing machine has a sluice facility. Policies and procedures are in place to deal with the safe handling of clinical waste. Staff members receive infection control training. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27. The numbers and skills mix of staff members are sufficient to meet the needs, and ensure the safety of the current service user group. EVIDENCE: Staffing levels, evidenced in staff rotas, and in numbers on shift at the time of this inspection were found to be appropriate and safe, in accordance with the care and social needs of the service users. Four care staff members; a maintenance worker, chef, laundry worker and the Registered Manager were on duty at the time of this inspection. One service user spoken with said that staff members were “very good”, another said “There is always somebody available to help” Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32. The home is managed properly and staff members receive guidance, which allows service users to receive consistent and quality care. EVIDENCE: The Registered Manager has worked in the home for a number of years. She has a management approach that creates an open, positive and inclusive atmosphere. Team, and service user meetings are held on a regular basis and enable staff members and service users to have a say in the way the service is delivered. Interactions between staff, service users and the Registered Manager were observed to be relaxed and positive. The Registered Manager demonstrated a commitment to equal opportunities at the time of this inspection. Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION x x 3 x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 x x x x x x Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 20 No. Are there any outstanding requirements from the last inspection? 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 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 10 Good Practice Recommendations The Registered Provider should ensure that staff members undertake refresher training in Dignity and Respect Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Croydon, Kingston & Sutton Office 8th Floor, Grosvenor House 125 High Street, Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beth Ezra Trust G53-G53 S19023 BethEzra V215231 020905 stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!