Inspection on 06/07/06 for Beth Ezra Trust

This inspection was carried out on 6th July 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 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 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 Key Unannounced Inspection 6th July 2006 11:15 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.V301725.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. Beth Ezra Trust DS0000019023.V301725.R01.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 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 Old age, not falling within any other category registration, with number (18) of places Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 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. A copy of the service’s Statement of Purpose and Service User Guide can be obtained on request from the Registered Manager. Fees for the home at the time of writing are £510.00 per week and there are no additional charges. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 6th July 2006 between 11.15 and 15.45. A partial tour of the premises took place and care records were examined. Observations of care practices also occurred. The Registered Manager and four staff members were spoken with, as were ten service users and one visitor. The views of nine relatives, one care manager and one general practitioner have been received via comment cards. The views of these people will be reflected in this report. What the service does well: This is, in general, a well run home were service users have there needs well met. The majority of feedback received about the home was very positive. One professional said that they were “Very impressed by the level of care in the home” A visitor said that there was always sufficient staff members on duty, that they were consulted with about their relatives care and that they were satisfied with the overall provision of care. Another visitor said that the staff members were kind and that the food was good. A further visitor said that the “facilities and staff care are excellent and I cannot think of a way that it could improve” One service user spoken with said “I like it here, its all good, good food and staff and very organised” Another service user said “they keep my bedroom neat and tidy and always knock before entering” There are good arrangements for ensuring that service user’s needs are assessed prior to them moving into the home and service users and their representatives are consulted with about the care to be provided on an ongoing basis. Service users have their health needs met well and are protected by good practice in handling medication. There are good arrangements for handling complaints and allegations of abuse. There are very good arrangements for ensuring that service users live a fulfilling lifestyle, in accordance with their wishes. Structured activities are provided daily and there are opportunities for service users to relax and spend time with their family members and friends. The home is comfortable, clean and very well maintained and there the grounds of the home offer a pleasant space to relax. Staff members are supplied in sufficient numbers and there is good staff training. All staff members are thoroughly vetted, offering a good level of protection to service users. There is good management of the home and a quality assurance system that takes into account the views of those using the service. Health and safety is taken seriously. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Three Requirements have been made following this inspection. There is a need to ensure that only those service users, who have needs that are registered in the home’ categories of registration are admitted. An application for a variation in the home’s categories of registration must be made in relation to two recently admitted service users. Whilst it is recognised that, in general, care planning in the home is good, there is a needs to ensure that care plans provide further detail about service user’s needs, and how these are o be met. Also, there is a need to ensure that care plans are reviewed at least once every month. There is a need to ensure that water available in service user’s bedrooms is distributed at a temperature close to 43 degrees. A recommendation as been made regarding the need to consult with the service user who receives liquidized meals, and offer them the opportunity of having each element of their meal purred separately in order that they are able to appreciate the individual tastes of the foods that they enjoy. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 6. There remain appropriate arrangements for obtaining information about the needs of service users before they move into the home which allow these needs to be met. This is a user-focused service with service users and their carers fully participating in the process of planning for their care and for their changing needs, this ensures that the wellbeing of service users is promoted and protected. However, at least one service user has been admitted to the home who has needs that the home is not registered to provided care for; it is therefore unclear at present whether this service user’s needs will be fully met. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 10 The home receives referrals mainly through private arrangements. Assessment information was examined for the two most recent admissions. Assessments included a short social history, risk assessments and details about the service user’s personal and health care needs. There were also medical reports that had been obtained from the service user’s General Practitioner. There was documentation detailing that service users and some family members are fully involved in this process. There was excellent feedback from service users, their relatives, and two visiting professionals about the home. One professional said that they were “Very impressed by the level of care in the home” A visitor said that there was always sufficient staff members on duty, that they were consulted with about their relatives care and that they were satisfied with the overall provision of care. Another visitor said that the staff members were kind and that the food was good. A further visitor said that the “facilities and staff care are excellent and I cannot think of a way that it could improve” One service user spoken with said “I like it here, its all good, good food and staff and very organised” Another service user said “they keep my bedroom neat and tidy and always knock before entering” One service user has recently been admitted to the home who has a diagnosis of dementia. Another service user is waiting for an assessment to determine whether they also have dementia. The home is not registered to provide care for people who have a diagnosis of dementia. The Registered Manager said that she is confident that the home could meet the needs of these two service users at present and it is the opinion of the writer that this is the case. However, should these two service users remain to live in the home, it is necessary that a variation in the home’s categories of registration be sought. The Registered Manager has agreed to apply for a variation to the home’s registration categories once she is in receipt of the reassessment of needs for one of these service users. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. There are, in general, good arrangements for ensuring that service users have their health, social and personal care needs well met, however, improvements must be made to the care planning process in order 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans for the two most recent admissions were examined. One care plan contained some information about the service user’s personal, health and social care needs and there were risk assessments in relation to moving and handling and pressure sores. There was information about personal care that said staff members should provide assistance “as necessary” The Registered Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 12 Manager said that the way that personal care is given to this service user changes, depending on the service user’s mood, which was why there was no further detail. It is necessary that care plans clearly detail the information needed by staff members to meet the needs of service user’s, in a way that they prefer. Care plans must include information about how the service user washes, bathes, dresses, and cleans their teeth and detail the action required by staff members to complete these tasks. This service user had lived in the home for over two months; however, there were no records available detailing that the care plan had been reviewed. It is necessary that care plans are reviewed at least once each month. A Requirement is made regarding these issues. Care records seen detailed that service user have access to a range of health care professionals and that the home is proactive in arranging health care appointments. There were records detailing that service users are registered with a general practitioner, have their weight monitored regularly and see opticians and dentists as necessary. One service user spoken with said that they received good support from the staff members with their health needs, and felt confident that health appointments would be arranged for them as necessary. There was positive feedback about the home from a visiting general practitioner. There are policies and procedures in place for ensuring that medication is handled safely. Medication Administration Records examined were accurate and up to date. One senior staff member confirmed that they had received training in the safe handling of medication and there was a record detailing all staff members who had received such training. This staff member demonstrated confidence in, and a good awareness of her responsibilities for handling medication safely. All medication was noted to be stored securely at the time of this inspection. Facilities are available for handling controlled medication. Some service users maintain responsibility for their own medication. The Registered Manager said that the home receives good support from the pharmacist and that regular audits of the medication system occur. Staff members were observed to treat service users with respect and to uphold their dignity. Staff members were noted to knock, and wait for a response before entering service user’s bedroom. One service user said that the cleaner always knocked before they entered their bedroom, and, if they did not want the cleaner to come in, this wish would be respected. Staff members in the lounge were noted to consult with service users about whether music should be played, what type of music, and what level of volume. Staff members consulted with service users at lunch time about what meal they would like and what portion size. Training records examined detailed that respect and dignity are discussed during the induction programme and the Registered Manager said that these topics are discussed regularly in staff meetings. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 13 Beth Ezra Trust DS0000019023.V301725.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. There continues to be a varied activities programme and wholesome and enjoyable meals are provided; therefore differing expectations and lifestyles are well catered for. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users continue to have good opportunities for social and recreational activities. There was an activities programme displayed in the lounge. This detailed that the hairdresser would be visiting the home in the morning and that there would be readings in the afternoon. It was noted that the hair dresser was working in the home at the time of this inspection. Service users spoken with said that they were happy with the range of recreational facilities available to them. Eight service users were observed to be taking part in a gentle exercise activity at the beginning of this inspection, and later partaking in a quiz. All service users appeared to be enjoying these activities. One service user said that they sometimes went out for a walk and to buy a newspaper with a staff member, and to the local library. Also, that they enjoyed going on the arranged outings about once every three weeks to the Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 15 coast, country side, or garden centres. This service user also said that their relative visited them regularly in the home. Service users have good opportunities for being involved in decision making in the home. There were records detailing that there are regular service user’s meeting, facilitated by staff members, were service users have opportunities to formally make decision about day to day life in the home. There was a weekly menu available that detailed that meals provided are varied, and that a choice is always available. Fresh, wholesome and nutritious food was available in the kitchen. The kitchen was very clean and well organised and food hygiene certificates were seen for staff members who work in the kitchen. A meal was sampled during this inspection. This was well presented and enjoyable. There was a very large selection of, at least, eight different deserts. The Registered Manager said that a good deal of attention is paid to providing a wide range of attractively present deserts in order to encourage service users to eat well. This is seen as good practice. Service users were noted to enjoy both the deserts, and main meal provided during this inspection. Hot and cold drinks are provided throughout the day, and on request. There was a fruit bowl in the lounge. All service users spoken with said that meals in the home are enjoyable and of good quality. One service user said, “The food is usually very good” Another service user said, “They always ask you what you want to eat” The cook said that specialist diets can be catered for and that they were currently catering for a service user who requires a liquidised diet. The cook said that all food was mixed together for this service user. It is strongly recommended that this service user is consulted with about their meals, and that they are given the opportunity of having each separate element of their meal purred separately in order that they are able to appreciate the individual tastes of the foods that they enjoy. Recent inspections of the service have rated this Standard as ‘excellent’ It is acknowledged that there continue to be, in general, very good arrangements for ensuring that service users eat well, however, this Standard is now rated as ‘good’ as it is considered that improved arrangements should be made regarding the provision of liquidized meals. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 16 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. 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. 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. 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. Records were available detailing that staff members have undergone training in the Protection of vulnerable adults Beth Ezra Trust DS0000019023.V301725.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 25 and 26. The home is maintained, decorated and furnished to a good standard and facilities are clean and, in general, safe. This ensures that service users live in a pleasant, homely and comfortable environment. However, there is a need to ensure that the water supply in service user’s bedrooms is at a temperature close to 43 degrees, and therefore, does pose a risk to health and safety. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home is well maintained and provides an extremely pleasant and homely environment to those who live there. There are large, very well maintained gardens to the rear of the property. The gardens containing a number of seating areas, and there are ramps providing access to wheelchair users. Some service users have been involved in the creation of a raised flower bed. There is parking available at the front of the building. The Registered Manager said that the London Fire and Emergency Planning authority have visited the Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 18 home since the last inspection. Records were not available detailing the outcome of this inspection; however, the Registered Manager said that the home complied with fire safety Regulations. There has not been a visit by the Environmental Health Officer since the last inspection of the home. Since the last inspection, building work has been completed on two bedrooms. These bedrooms now comply with National Minimum Standard space Requirements, and have en-suite facilities. A service user living in one of these rooms said that they were “Very happy” with their new bedroom. Other bedrooms seen were well decorated and homely. Service users had personalised their bedrooms with their own ornaments, pictures, photographs and some furniture. One service user said that they liked their bedroom and that they had a lovely view of the garden. Water temperatures from sinks in five bedrooms were tested. In general, water was distributed at a safe level and there were records detailing that regular checks on water temperatures in the home occur. However, water distributed for a sink in bedroom 25 was at 48 degrees. This temperature exceeds the safe temperature detailed in National Minimum Standards. A Requirement is made regarding this issue. All areas of the home viewed were noted to be clean and free from offensive odours. Laundry facilities are suitable and there are policies and procedures for the control of infection. Beth Ezra Trust DS0000019023.V301725.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staff members are provided in sufficient numbers and the procedures for the recruitment of staff are robust and provide the safeguards to offer protection to people living in the home. There is a very good staff training and development programme that provides staff members with skills necessary for meeting the needs of service users. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staffing levels appeared to be appropriate, and in line with the needs of current service users at the time of this inspection. As well as care staff, there was the Registered Manager, a cook, a hairdresser and a maintenance worker on shift. There was feedback from staff members, service users, and visitors that staffing levels are sufficient. Three new staff members have been employed to work in the home since the last inspection. Personnel files for these staff members were examined. Files contained all the information and documentation required and there was documented evidence that all required checks had been carried out prior to the staff members commencing work in the home. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 20 Records available detailed that each new staff member had undergone a detailed induction programme and that the Registered Manager had been satisfied that the staff member had understood the information provided to them during induction. Of the two new care staff members, one had a certificate detailing that they had a qualification at NVQ Level 2 in Care, and there were records detailing that the second was currently undertaking this qualification. There were records detailing that the new staff members had completed training in moving and handling and in food hygiene, and that they had been required to read the home’s policies and procedures. There were records indicating that staff training has been ongoing since the last inspection. One senior staff member said that they had recently completed the NVQ Level 3 in Care qualification. Beth Ezra Trust DS0000019023.V301725.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): There continues to be good management and an excellent quality assurance system, which ensures that the home is run in the best interests of service users. Health and safety is taken seriously. This ensures that the health and well being of service users is protected. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There continues to be a qualified an experienced Registered Manager in post. Staff members spoken with said that they received good support and guidance from the Registered Manager. There was feedback for service users and their representatives that the Registered Manager consulted with them, and kept them informed about things that were important. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 22 There is an annual development plan for the home and a number of tools for self- monitoring. Service users and their family members and staff members are surveyed on a regular basis about their views on the home. A qualitymonitoring group then collate the results of surveys and compile an annual report. There were minutes of a service user’s meeting that detailed that feedback has recently been given to service users about the results of quality monitoring in the home. There were records detailing that staff members are trained in safe working practices such as moving and handling, food hygiene, infection control and first aid. Records also indicated that there are regular safety checks on water temperatures, fridge and freezer temperatures, the fire alarm, emergency lighting, fire fighting equipment, and door guards. There are regular fire drills, boiler safety checks, gas and electricity safety checks, portable electrical appliance safety checks and testing for legionella. There are risk assessments in place for chemicals and all accidents and incidents are recorded. Beth Ezra Trust DS0000019023.V301725.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 X X 3 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X 2 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 X X 3 Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 24 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. 1 Standard OP4 Regulation 12 (1)(a) Requirement The Registered Provider must ensure that an application is made to the Commission for Social Care Inspection for a variation in registration categories, in relation to the new admissions that have a diagnosis of dementia. Only service users who have needs that are reflected in the home’s registration categories must be admitted. The Registered Provider must ensure that: 1. Each service user has a care plan that clearly details how all of their personal, health and social care needs will be met. 2. Is reviewed at least once monthly. 3 OP25 13 (4)(a) The Registered Provider must ensure that water available in service user’s bedrooms is distributed at a temperature close to 43 degrees. DS0000019023.V301725.R01.S.doc Timescale for action 01/09/06 2 OP7 15 (1)(2)(b) 01/09/06 01/09/06 Beth Ezra Trust 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. 1 Refer to Standard OP15 Good Practice Recommendations The Registered Provider should consult with the service user who receives liquidized meals, and offer them the opportunity of having each element of their meal purred separately in order that they are able to appreciate the individual tastes of the foods that they enjoy. Beth Ezra Trust DS0000019023.V301725.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston 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 DS0000019023.V301725.R01.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. 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. 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