Inspection on 08/12/05 for Beth Ezra Trust

This inspection was carried out on 8th December 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 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 Unannounced Inspection 8th December 2005 08:57 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.V271013.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 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.V271013.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2 September 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 DS0000019023.V271013.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 8th December 2005 between 08.57 and 12.15. A partial tour of the premises took place and care records were examined. The Registered Manager and five staff members were spoken with. A number of service users and one visitor were also spoken with. What the service does well: What has improved since the last inspection? There have been a number of areas of improvement since the last inspection. Two bedrooms have been extended to ensure that they comply with National Minimum Standard size requirements; en-suite facilities have been provided in these rooms. Night-lights have been provided in each bedroom, and the call Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 6 bell system has been improved in order to provide less disruption to service users. There is a quality-monitoring group. The chair of this group said that work is currently being undertaken to ensure that quality monitoring ensures good outcomes for service users. Staff training has been ongoing. All staff members have undertaken training in ‘Safeguarding Residents Rights’ since the last inspection of the home. 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 DS0000019023.V271013.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were assessed during this inspection. All key Standards were found to have been met at the last inspection of the home. EVIDENCE: Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10. 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. EVIDENCE: 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. One service user pointed out a locked tin in their bedroom where they stored their medication. The Registered Manager said that the home receives good support from the pharmacist and that regular audits of the medication system occur. Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 10 Respectful interactions between staff members and service users were observed. Staff members consulted with service users and were respectful of their wishes. Staff members knocked on bedroom doors, and waited for a response before entering. Records were available detailing that all service users have recently had their care reviewed and that they were consulted with during this process. Induction records for a recently appointed staff member detailed that they had received training in dignity and respect, and since the last inspection of the home, all staff members have attended a workshop in ‘Safeguarding Residents Rights’ Feedback received from service users was that they were very happy with the care that they received from staff members. A visitor spoken with said that their relatives’ wishes were respected. Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15. Varied activities and wholesome and enjoyable meals are provided; therefore differing expectations and lifestyles are well catered for. EVIDENCE: Service users have good opportunities for social and recreational activities. Staff members are proactive in finding out how service users want to spend their time, and arranging activities in line with their views. The results of a service user satisfaction survey, undertaken at the beginning of the year had been assessed by the home. The survey highlighted that service users would like music to be played in the lounge during the day, and this was happening at the time of this inspection. 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. There was also a notice detailing that the home organises regular video evenings. There is a dedicated activities coordinator employed in the home on a part time basis. This person was not on shift during this inspection, but staff members played carpet bowls with service users and facilitated a quiz. Service users spoken with said that they were happy with the range of recreational facilities available to them. One service user said that they preferred to spend time in their bedroom listening to the radio. Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 12 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. Hot and cold drinks are provided throughout the day, and on request. Fresh fruit was provided with the morning coffee, and a staff member said that cakes are served with afternoon tea. 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 chef is very good” Another service user said, “meals are generally very good” A main meal is served at lunchtime, with a lighter meal being served at teatime. A staff member reported that it was a service user’s birthday today so they would get to choose the evening meal. Some specialist diets can be catered for. The home is currently catering for a service user who requires a liquidised diet, and a service user who requires a diabetic diet. At previous inspections this Standard has been found to be exceeded as a result of the consultation process with service users about food. This has not changed and the home continues to exceed this Standard. Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. 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. 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. One staff member spoken with demonstrated a good awareness of adult protection issues. Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. The home is maintained, decorated and furnished to a good standard and facilities are clean and safe. This ensures that service users live in a pleasant, homely and comfortable environment. EVIDENCE: The home is a large detached property. There is a large car park at the front of the property, and a large, and very pleasant garden to the rear. The grounds and garden were tidy and safe and accessible to service users. The home was decorated and furnished to a good standard and there is a routine programme of maintenance and redecoration. There was a maintenance worker on shift at the time of this inspection. The home is laid out over two floors, accessed by lift or stairway. Since the last inspection of the home an extension has been added to the front of the building. This has added extra space to two bedrooms that previously did not meet space requirements as laid out in National Minimum Standards. En-suite facilitates have also been provided in these bedrooms. Risk assessments had been completed regarding this building work. A service user, who had moved out of their bedroom whilst Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 15 this work took place, said that she had been consulted with regarding this move. The local fire officer visited the home one week ago. There were no records detailing the outcome of this visit, but the Registered Manager confirmed that the home was found to be safe. There were records detailing that the fire officer had visited the home in January 2005 and made no requirements. The local environmental health officer visited the home in April 2005. A new call alarm system has been put in place since the last inspection of the home. The Registered Manager said that this has allowed staff members to respond to calls in a more effective manor, and is less disruptive to service users. Bedrooms viewed were 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. Thermostatic valves are fitted on all hot water outlets in bedrooms, communal toilets and bathrooms. Water distributed from a random sample of outlets throughout the home was found to be at a temperature close to 43 degrees. There were records detailing that water temperatures are checked to reduce any risk of scalding. Emergency lighting is provided throughout the home. Each bedroom has been fitted with a night light since the last inspection. A staff member said that this new system allows night staff members to be more discrete when carrying out night checks of service users. Service users are provided with a key to their bedroom if this is their wish and there is a lockable cupboard in each bedroom. All bedrooms viewed had been personalised and looked comfortable and cosy. The home was found to be clean, hygienic and free from offensive odours and there was cleaning staff members on shift. The laundry is appropriate and a worker is employed solely for the purpose of doing laundry work. One service user spoken with said that they were happy with the home’s laundry service. Records detail that staff members receive infection control training. Service users spoken with confirmed that they were satisfied with hygiene standards in the home. Hand washing facilities are prominently sited. Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 16 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): 28, 29 and 30. 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. EVIDENCE: There was an NVQ Assessor working with one care staff member at the time of this inspection. Two staff members are currently undertaking NVQ Level 3 in Care, and two staff members are undertaking NVQ Level 2 in Care. Files were examined for the two most recently employed staff members. Both files contained all information and documentation required by Regulation for the protection of service users. There are good arrangements for staff training. The home has implemented an induction and foundation training programme that is in line with Skills for Care specifications. Records were available detailing that the most recently employed care staff member had undergone a thorough induction programme that had been supervised by the Registered Manager. There were certificates in this staff member’s training files that detailed that they had attended training in Infection Control, Health and Safety and Moving and Handling. Food Hygiene certificates were seen for staff members who work in the kitchen. There has been training in ‘Safeguarding Residents Rights’ for all staff Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 17 members since the last inspection of the home. Additionally, records indicate that there have been a number of study sessions held for staff members in the last year including Dignity and Respect, Medicine for the Elderly, Health and Safety, Moving and Handling, First Aid, Colostomy Care, Infection Control, and Prevention of Abuse. Staff members spoken with said that the home offered good opportunities for training. One staff member was clear about what to do in the event of a fire, another staff member demonstrated a good awareness of issue relating to the protection of vulnerable adults. Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 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 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): 33, 35 and 38. There is 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. EVIDENCE: There was 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. Reports from past surveys were available in the home. The chair of the quality-monitoring group was spoken with; She reported that there are five members in the group and these members consult on a regular basis with Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 19 service users. The current work of the group is to raise its profile amongst service users and their representatives by attending coffee mornings in the home. A quality-monitoring questionnaire has recently been distributed, and the results of this survey will hopefully be made available in January 2005. The chair of the quality monitoring group said that results will analysed, a report will be complied and this will be discussed with service users at meetings. The results of a quality monitoring survey held last year were available for inspection. A number of suggestions made by service users have been implemented by the home. Service users generally maintain control over their own finances. The home has facilities for the safe keeping of some money for service users. Records were available detailing the amount of money held by the home for service users and there were receipts were service users had taken out money. Records of staff training detail that staff members must undergo training in safe working practices as part of their induction programme and that refresher training occurs regularly. There are regular fire drills and testing of the fire alarm and fire fighting equipment is available throughout the home. Magnetic door guards have recently been checked. Portable appliances are safety checked, records indicate that the most recent checks occurred in July 2005. There was a certificate detailing that the emergency lighting was checked in November 2004, and that in-house checks also occur. The lift was serviced in September 2005 and hoist and baths were serviced in January 2005. Gas systems were checked in June 2005. There were risk assessments in relation to the environment, fire and safe working practices. Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 20 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 4 X 3 X X 3 Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beth Ezra Trust DS0000019023.V271013.R01.S.doc Version 5.0 Page 22 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. 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