Inspection on 01/02/06 for Bethany

This inspection was carried out on 1st February 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

Bethany 21/09/07

Bethany 11/12/06

Bethany 10/08/05

Bethany 24/02/05

Bethany 04/10/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Bethany 190 Hawthorn Road Bognor Regis West Sussex PO21 2UX Lead Inspector Mrs A Taggart Unannounced Inspection 1st February 2006 02:00 Bethany DS0000014397.V279990.R01.S.doc Version 5.1 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 Bethany DS0000014397.V279990.R01.S.doc Version 5.1 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 Adults 18-65. 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. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bethany Address 190 Hawthorn Road Bognor Regis West Sussex PO21 2UX 01243 866260 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) L`Arche (Registered Office) Post Vacant Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 5 persons in the category LD (persons aged 18-65) and one person in the LD/E category (person over the age of 65) with a learning disability 10th August 2005 Date of last inspection Brief Description of the Service: Bethany is registered as a care home providing personal care for a maximum of five adults with learning disabilities. The property is a detached house situated in a residential area on the outskirts of Bognor Regis. The accommodation for service users is arranged on two floors and includes five single bedrooms two on the ground floor and three on the first floor. The lounge, kitchen, quiet area, conservatory and laundry are located on the ground floor. The third floor of the house is used for living-in staff. Bethany is one of three homes operated locally by LArche, a voluntary organisation. The Responsible Individual is Mr. Chris Bemrose and the Registered Managers post is currently vacant. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out at 2.30pm and lasted for 2.4 hours. Service users were out at day care facilities at the start of the visit but came home and were spoken to later in the day. During the visit a tour of the home was undertaken during which all bedrooms and communal areas were seen. The care plans of all five residents were seen with any issues being tracked and discussed with the staff member on duty. Documents in regard to the running of the service were also seen including menus, health and safety records and maintenance checks. At this visit staff records were not seen, as the acting manager was not on duty. The files of all the current staff team were seen at the last visit and all were in good order. The staff member confirmed that no new staff members had been employed. Team member Zenia Grigorjevas was on duty and assisted with information during the visit. What the service does well: What has improved since the last inspection? Care plans have been reviewed and updated and are now kept in a form that is easily accessible for staff to read. Support plans for assisting residents with room cleaning are now in place and the standard of cleanliness in the home has improved. Communal areas have been re-carpeted and a call bell system has been fitted to one bedroom. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 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. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 There is sufficient information available to enable prospective residents and their families to make a choice about the home. At the present time the Service Users Guide is being produced in an accessible format. EVIDENCE: The L’Arche organisation produces corporate documents in respect of these Standards, which are then personalised for each home. All of the documents were found to be in good order at the last visit and no new residents have been admitted to the home since then. At the present time there is a draft in place of an accessible Service Users Guide specifically for Bethany. Residents are involved in the process and the document will use words, pictures and symbols. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 9 10 There is sufficient information available to inform the staff team of the needs of the people they support. EVIDENCE: Each person living in the home has a plan of care in place in place, which details all of their health and social care needs. Plans contain information regarding personal care, social activities, nutritional needs, self-development goals and friends and family connections and are updated on a regular basis. There is evidence that residents are encouraged to be as independent as possible and are supported to take risks in a safely managed way. Full care reviews are held on a six monthly basis and if appropriate, families, care managers and other professionals are involved. Care plans are now kept in a way that makes them easily accessible to staff members. As good practice a place should be made available on the plans to show monthly reviews and updates are carried out. The L’Arche organisation has a confidentiality policy in place and all records are securely kept in the office of the home. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 10 Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 14 15 16 17 Resident’s lifestyle choices are respected and encouraged and a variety of activities both educational and social are made available. EVIDENCE: The people living in the home access a wide variety of activities including educational opportunities, social activities and religious worship. Records show that people attend colleges, a horticultural project and other educational opportunities, and goals for future development for people are agreed with them and supported by the staff team. L’Arche is a Christian based organisation, where residents are encouraged to practice fellowship and worship but people attend churches of differing faiths and can also choose not to attend if they wish. Residents access local clubs, café’s and other social activities and there is evidence of regular input from families. One resident coming back from college indicated that they were happy with their day and that they enjoyed the courses they were undertaking. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 12 Menus show that a variety of fresh, home cooked food is available and special diets such as vegetarian and gluten free can be catered for. The staff member on duty said that usually people sat at breakfast and chose together what the evening meal would be and there were also regular celebrations both in Bethany and the other houses close by. People also go out for meals, usually at week- ends or days off day activities. There is evidence that residents are included in cooking meals and people also make their own packed lunches and snacks. At the present time a pictorial menu book is being compiled to aid those residents who do not have good verbal communication. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 21 Personal care and healthcare needs are recorded in the plan of care and the home works in conjunction with other healthcare professionals. Medication was in good order. EVIDENCE: The health and personal care needs of each resident are recorded in their care plan and are regularly reviewed and updated. Residents are supported to be as independent as possible regarding personal care but plans also detail their support requirements and need for observation. The home works closely with other healthcare professionals and there is evidence of input from the community learning disability team, psychiatrists, psychologists and occupational therapists Emotional well-being is also assessed with counselling being made available if needed. Staff members receive training in understanding the needs of older people with a learning disability and wherever possible, people can stay in their own home until the end of their lives. The home has an agreement with a local pharmacy and medication is securely stored in the office of the home. Staff members receive training in the Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 14 administration of medication during induction and the administration and recording system was found to be in good order. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 The home has a complaints procedure in place and any complaints or concerns are taken seriously and acted upon. EVIDENCE: The home’s complaint procedure is produced in an accessible format and a copy is posted on the notice board. There is evidence that “grumbles” from residents are acted upon and discussed as soon as possible and no formal complaints have been recorded since the last visit. A weekly house meeting is held, where residents are encouraged to air their views and there are also opportunities to speak to people outside the home. The home has a policy on the protection of vulnerable adults from abuse and there is a “Whistle blowing” policy in place. As good practice, the policy should be further reviewed to ensure it meets with current guidelines. The staff member on duty was aware of their responsibilities should they suspect an abuse had taken place. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 Levels of hygiene in resident’s rooms have been improved and the home offers a comfortable, warm and homely environment. EVIDENCE: The communal areas of the home were attractive, warm and comfortable and all carpets had recently been cleaned. The staff member on duty said that there was a financial plan in place to refurbish the lounge with redecoration and a new suite and an agreement had also been reached for the refurbishment of the upstairs bathroom. Since the last visit the carpets in the lounge, hall and stairs have been replaced and now look much better. Resident’s bedrooms have all been personalised to their individual taste and show evidence of their hobbies and interests. There has been a great improvement in the cleanliness standards in the rooms and each resident now has a plan in place, which identifies support needed from the staff team to keep their rooms clean and hygienic. Hand- rails and grab handles are in place and there is also an assisted bath to aid mobility. One resident has requested a call aid to be fitted in their room to make them feel safer at night and this has been provided. The home was clean and hygienic throughout. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 17 Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 The staff team are committed and caring, they receive induction and training and are well supported. EVIDENCE: During the visit there was one staff member on duty and another person was due when people came back from day care. The rota showed that often there are three people in the evening to enable residents to access social activities. One staff member is also on call during the night. Staff members appointed by L’Arche live in the home sharing lifestyles and personal development opportunities alongside the people they support. When residents came back from day care, the staff on duty were seen to greet them in a kind and friendly manner and asked if there was anything they wanted. All new staff members receive an intensive induction programme in line with current learning disability requirements and during this time they access mandatory training. There is also a programme of further training available, which includes medication, challenging behaviour, protection from abuse, and health and safety. Staff on duty confirmed that formal supervisions are held every eight weeks and notes show that work practices and professional development are discussed. Staff members also have access to an outside “supporter”, who is Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 19 part of the L’Arche community, where they can discuss personal issues and gain emotional support. The staff member said that this was invaluable as many of the staff team are from other countries and away from home. As the acting manager was not available, staff records were not seen at this visit. However no new staff members have been employed recently and the records for all the current staff team were seen to be in good order at the last visit. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 41 42 The home is currently being run by an acting manager who is working hard to improve systems and work practices. EVIDENCE: The acting manager was not available during the visit but the staff on duty spoke highly of him and said he was caring, approachable and lead by example. It is obvious that there have been improvements made to both work practices and systems since the last visit and a plan was seen which indicated areas highlighted for continuing improvements to the service. The Registered Provider has confirmed that an application will be made for the acting manager to be registered in the near future. There is evidence that residents are involved in the running of the home and there are many opportunities for them to influence the management of the L’Arche organisation by being involved in meetings at all levels. Residents have access to advocacy services and are encouraged to give feedback on the service they receive. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 21 Records for the running of the service were seen including health and safety audits, fire checks and training, gas, electrical appliance testing and regular maintenance checks. All were current and in good order. As good practice a place should be made available to record the monthly reviews of care plans and the adult protection policy should also be reviewed to ensure it meets current guidelines. No requirements have been made as a result of this visit. Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 X 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 X 3 3 x Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 23 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 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 Bethany DS0000014397.V279990.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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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