Inspection on 11/12/06 for Bethany

This inspection was carried out on 11th December 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bethany 21/09/07

Bethany 01/02/06

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 11th December 2006 03:00 Bethany DS0000014397.V319772.R01.S.doc Version 5.2 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.V319772.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 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.V319772.R01.S.doc Version 5.2 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) Benjamin Stockdale Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Bethany DS0000014397.V319772.R01.S.doc Version 5.2 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 1st February 2006 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 Manager is Ben Stockdale Current fees are £ 650 to £853 per week. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit was carried out at 2.30pm in order to meet with service users when they returned from day care. Prior to the visit the inspector read the last two reports and any other documentation and correspondence regarding the service and completed a planning document. A pre-inspection questionnaire was sent to the manager, survey forms to service users and comment cards to families and professionals. The inspector also spoke to a family member via the telephone who said they were very pleased with the home and felt that their family member was well supported in all areas of their life. Comment cards and survey forms received back made very positive comments about the manager, staff team and care provided in the home. During the visit, the inspector spent time with two of the five service users, the others having gone to a party and also observed interactions with staff and their involvement with the running of the home. A tour of the building was undertaken during which communal areas and private bedrooms were seen and service users said they were happy with the facilities provided. The inspector tracked three care plans and followed up on any concerns or relevant information with Meghan Zack, the staff member on duty. The files of two new staff members were also seen and were in good order. The main meal of the day was being prepared; service users were involved and were given a choice. One service user was making their own packed lunch for the next day and all said they enjoyed the food provided. Records for the running of the business were seen including medication records, fire checks and staff fire training, maintenance records and the complaints book and all were in good order. The registered manager of the home Mr. Stockdale had completed and returned the pre-inspection questionnaire and information from this document has also been used to inform the visit. Mr. Stockdale was on sick leave but kindly came to the home to provide staff records and other documentation. Team member Meghan Zack assisted with the visit and the Responsible Individual Mr. Bemrose received feedback. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: In order to ensure that people are protected from the risk of infection, all areas of the home should be always be kept clean and hygienic. In order to ensure that the correct procedures are followed, the staff team should receive formal training from a healthcare professional on the administration of insulin injections and the training should be recorded. Bethany DS0000014397.V319772.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. The summary of this inspection report can be made available in other formats on request. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 8 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.V319772.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 3 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their families can be confident that a pre-admission assessment of their needs will be carried out, they will be able to visit the home and a contracts of terms and conditions of residency will be agreed. EVIDENCE: There is a Statement of Purpose and Service user Guide in place and some information about the home is available in an accessible format using pictures and signs. No new service users have been admitted since the last visit and all of the people currently living in the home have pre-admission assessments on file and have a contract detailing terms and conditions of residency in place. The parent of a service user confirmed that they had been involved in the admission process, had received information about the home and encouraged to visit, before making a decision about whether the home would meet their needs. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs of each person is detailed in a plan of care and the staff team are aware of the ways in wish service users want to be supported. EVIDENCE: There are comprehensive care plans in place, which have been generated from information recorded from the pre-admission assessments. The plans contain detailed information to inform the staff team of the needs of each service user and include social needs, personal care agreements, and agreed personal goals for future development. The development of personal goals are then tracked through daily records and show that the home follows a “person centred” approach. There is evidence from records and daily plans that service users are involved in all aspects of the running of the home and are supported to be as independent as possible. Records of regular six monthly care reviews were in place and families and care managers are invited. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 11 Comments received back from families said that they were involved with the care of their family members and were invited to meetings, family days and care reviews. All of the care plans had been recently reviewed and some had detailed updated additions regarding changing needs in place. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have access to a variety of educational and social opportunities and are involved in their local community. EVIDENCE: There are a wide variety of activities and educational opportunities available to ensure that service users can develop their skills and access the wider community. During the visit, people were coming back from day care activities and said they had enjoyed the day. One person said, “I have had a good day, have been working on computers this afternoon and did gardening in the morning, I was doing things about Narnia, I like it here and I am happy. I like going home to see my family”. Another person said, “This is a good place to live and I like making my own sandwiches, doing my knitting and going to the pub”. Two people had gone straight from day care to a surprise party for a staff member at another L’Arche home. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 13 Service users access religious services and there is also an ethos of worship within the home. There was evidence in records that people go shopping, to pubs, clubs, discos and the cinema and people also visit their families and go on holiday. Menus and food records show that a variety of healthy, fresh, home cooked meals are available and service users likes and dislikes are recorded. The main meal of the day was Chicken Kiev with rice, vegetables and sauce with yoghurts or fresh fruit to follow. One service user came in from day care, went to the fridge and made their own packed lunch, ready for the next day. Records show that special diets are catered for and service users also enjoy meals out on a regular basis. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The healthcare needs of service users are assessed and recorded and the home works with a variety of healthcare professionals. Further staff training should be sought from a healthcare professional regarding the administration of insulin EVIDENCE: There is evidence both from records and from talking to families that the healthcare needs of service users are a high priority within the home. Records show that the staff team works with other healthcare professionals such as the local learning disability team, psychologists, psychiatrists and nutritional advisors and people regularly attend the dentist and chiropodist. A family member said, “Ben (The manager) keeps you in touch with everything. Recently my son had to go to the hospital for blood tests, which could have caused anxiety and the staff spent time explaining to him exactly what would happen when he got there. He was well prepared and well Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 15 supported and there wasn’t a problem. I cannot fault the home on their medical care. Medication is securely stored in the office of the home, staff receive medication training and the records was found to be current and in good order. Although generally healthcare outcomes for people are good, for one service user it was noted that staff team administer insulin injections on a regular basis but there was no evidence that staff have received formal training from a healthcare professional. In order to ensure that the staff team are aware of the correct procedures to follow training should be carried out by a healthcare professional, such as a district nurse, the training should be recorded and as injections are an intrusive procedure, if possible an agreement sought from the service user as to who will administer the medication. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are recorded and acted upon and service users are protected by the staff team’s awareness of adult protection procedures. EVIDENCE: The home has an accessible complaints procedure, a copy of which is included in the Statement of Purpose and there is also an accessible format using pictures and symbols to aid service users to make a complaint. A family member said, “I have never had a reason to complain but would feel fine about doing so”. Records show that complaints are recorded and acted upon in a timely manner and service users said they would talk to the staff if they were unhappy. All of the staff team receive training on the protection of vulnerable adults from abuse and there is evidence in training files that annual updates are also held. The staff member on duty was aware of their responsibilities should they suspect any form of abuse had occurred and said that new staff work alongside a mentor until their induction period is confirmed. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 26 28 and 30 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Although the home is comfortable and meets the needs of service users, hygiene levels should be maintained in order to protect people from the risk of infection. EVIDENCE: Bethany was warm, homely and comfortable and service users said that they were happy with their home. Recently the lounge has been redecorated with new furniture purchased and looks attractive and comfortable. There are also a variety of books, videos, games, a music system and a large television, for people to use. There is a modern, well-equipped kitchen and a large conservatory dining room, leading to an easily accessed and well-maintained garden. During the visit, a new central heating boiler was being fitted. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 18 Service users private bedrooms have been personalised to suite their requirements and had personal belongings, music systems and people’s craftwork displayed. Despite there being a written plan in place with regard to service users being supported to keep their rooms clean, two bedrooms were very untidy and needed to be cleaned. The staff member on duty said it was very difficult to support the two people concerned, as they did not like staff going in their rooms. As good practice the support plans should be reviewed and risk assessments carried out regarding the refusal of people to accept help. Generally the communal areas of the home were clean and hygienic but would benefit from paintwork being cleaned, especially on the stair rails and doors to protect people from the risk of infection. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Service users are supported by a kind, caring and well supervised staff team EVIDENCE: As all service users were out at day care, there was only one staff member in the home. Later when people came home two staff were available. There has been a high level of sickness and compassionate leave in the home recently, which has put a lot of responsibility and strain on remaining staff members who have tried to ensure that service users lifestyle choices are not curtailed. Staff from other L’Arche homes have provided cover and the Responsible Individual, Mr. Bemrose was working the late shift on the day of the visit. Mr. Bemrose said that the senior management of L’Arche were currently discussing how an emergency staff plan could be put into place in order to deal with such circumstances, rather than relying on the goodwill of existing staff. New staff receive an intensive induction programme in line with the Learning Disability Awards framework and during this time they attend all mandatory Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 20 training , medication, challenging behaviour and adult protection awareness. Mr. Stockdale said that 50 of the current staff team have an NVQ award. The staff member on duty confirmed that they received regular supervision and records were seen on file. The people living in the home are protected by a robust recruitment procedure and the staff records for two new staff members were seen. Both contained all of the necessary documentation including a current Criminal Bureau Check and two references. Both families and service users spoke very highly of the staff team at Bethany and said they were committed, kind and caring. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 41 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service A competent and caring manager runs Bethany in the best interests of service users and records are in good order. . EVIDENCE: The manager of the home has recently successfully undergone the process to become the registered manager and is currently working towards achieving the Registered Manager’s Award. Families and staff members were complimentary about Mr. Stockdale’s management style and said that he was approachable and supportive. The staff member on duty confirmed that they received regular supervisions and support sessions and records were seen on file. Mr. Stockdale as off on sick leave the day of the visit but kindly came to the service to provide staff records and other documentation. Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 22 The L’Arche organisation carries out an annual audit, which seeks the views of service users, families and staff and the outcomes are used to inform the organisational mandate for the following year. In order to fully meet the requirements of a quality assurance process, comments and views should also be sought from other professionals involved with the home and the results published. Mr. Bemrose said that this would be addressed. The manager does not act as financial appointee for any of the people living in the home and where monies are held on behalf of people, they are locked in a safe, transactions are recorded and receipts kept. The monies of one service user was checked and found to be correct. Records for the running of the business were seen including the fire records, gas, electrical and maintenance records and all were current and in good order. Monthly health and safety audits are undertaken and all staff receive health and safety training. Records are kept of the audits and show that any identified problems are acted upon in a timely manner. As a result of this visit two Requirements were made regarding staff training and the cleanliness of the home. Bethany DS0000014397.V319772.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 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 X 2 3 3 3 4 3 5 3 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 X 26 3 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 X 3 3 x Bethany DS0000014397.V319772.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 YA20 Regulation 13.2 Requirement Timescale for action 2. YA30 23.2 (d) The registered manager should ensure that the staff team 30/01/07 receive training in the administration of insulin injections and that the training is recorded. To ensure that people are protected from the risk of 30/01/07 infection, the registered manager should ensure that cleanliness and hygiene levels are upheld in all areas of the home. 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.V319772.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 1. Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bethany DS0000014397.V319772.R01.S.doc Version 5.2 Page 26 - 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. 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