Inspection on 11/05/05 for Bethany House

This inspection was carried out on 11th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bethany House 29/08/07

Bethany House 26/02/07

Bethany House 28/11/06

Bethany House 31/10/05

Bethany House 02/11/04

Bethany House 19/05/04

Bethany House 12/02/04

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

CARE HOMES FOR OLDER PEOPLE Bethany 434/436 Slade Road Erdington Birmingham B23 7LB Lead Inspector Brenda ONeill Unannounced 11th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bethany Address 434/436 Slade Road Erdington Birmingham B23 7LB 0121 350 7944 0121 624 7311 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Joseph Alphonse Rodrigues Mr Joseph Alphonse Rodrigues Care Home 30 Category(ies) of Older People, Dementia registration, with number of places Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That one named person, who is under 65 years of age at the time of admission can be accommodated and cared for in this Home. Date of last inspection 2 November 2004 Brief Description of the Service: Bethany House is a registered care home for 30 elderly people and is located North of the City Centre in Erdington and close to the M6. It has easy access to community facilities and public transport which runs directly outside the home. The home was originally four houses that have been tastefully converted into one large care home offering a very good standard of accommodation. Accommodation is offered over two floors with six double and eighteen single bedrooms all with en-suite toilet and wash hand basins. There are three lounges and a large dining room located on the ground floor, toilet, bathing and showering facilities are located throughout the home. There is also a hairdressing room, large kitchen with a small area attached for residents to prepare drinks, medical room, laundry and office space. The front of the home has been block paved and has ramped access and ample parking space. To the rear of the home is a very large patio area that has been block paved to match the front and offers ample space for the residentss with a water fountain feature, raised flower beds and seating available. Access to the grounds is via the dining room and two bedrooms on the ground floor have direct access to the grounds. Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over three and a half hours in May 2005. This was the first of the statutory inspections for this home for 2005/2006. During the inspection a tour of the premises was made during which some bedrooms were inspected, two resident files and other care documentation was inspected. As the manager was not on duty some documentation was not accessible as it was locked in the office for reasons of confidentiality. The inspector spoke with two senior staff and seven of the 23 residents. What the service does well: What has improved since the last inspection? All bedrooms in the home have had new locks fitted that enabled the residents to lock their doors whilst in their rooms or when leaving them ensuring privacy of their personal possessions. There was evidence on residents files that they had been consulted about the furnishings in their bedrooms to ensure they were happy with what they had. The manager had increased the frequency of notifications to the CSCI of any accidents or incidents in the home to enable the inspector to monitor the home better between inspections. Bethany CS0000016765.V180616.R01.doc Version 1.30 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 CS0000016765.V180616.R01.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. The assessment procedures in the home are inadequate therefore the needs of the residents are not known by staff at the time of admission. EVIDENCE: Two resident files were sampled and there was evidence that the homes staff had carried out a pre-admission assessment for each of the individual’s. The assessments were very brief and did not detail the individual needs of the residents and it was difficult to see how staff had determined they could meet the needs of the individuals. Bethany CS0000016765.V180616.R01.doc Version 1.30 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 standard(s) 7, 8, 9 and 10. The care plans did not detail how the individual needs of the residents were to be met and strategies for managing risks were not clearly identified. Health care needs were being met and the system for the administration of medication was good with the exception of one resident for whom it could not be determined whether he was receiving the correct dosage. EVIDENCE: The files of two of the most recent admissions to the home were inspected. One of these had only some basic details about the resident concerned and nothing that could be described as a care plan. From this resident’s daily records it could be determined that she was quite self-caring in relation to her personal care. The inspector spoke with this resident and she spoke about her hearing aid however there was nothing included in her file in relation to the care of this. The other file did include a care plan but this was quite basic and stated such things as ‘requires assistance with washing/dressing’ but the type of assistance was not detailed or how much this person was able to self-care. Neither of the files contained manual handling risk assessments and only tick lists for personal risk assessments. There were records for both residents to evidence they had seen the optician and the doctor. Those residents spoken with were happy that their medical Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 10 needs were being met and confirmed that if they asked to see the doctor this is arranged for them. It was also confirmed by them that see the chiropodist on a regular basis. The district nurse was at the home when the inspector arrived to administer insulin to a resident and check the dressings of another resident. There was evidence in the home of aids for the prevention of pressure sores being sought and for the management of continence. The files inspected did not include nutritional screenings or assessments for tissues viability. These were needed as they would highlight any potential risks for residents and any areas that needed to be monitored by staff. There had been no changes to the medication administration system since the last inspection which was generally well managed with some minor requirements being made including: - The amounts of PRN (as and when required medication) in the boxes must correspond with the amounts received and those administered. - All eye drops must be dated when opened. - There must be a complete audit trail for Warfarin as there was for the other medication. The inspector did not observe any issues in relation to the privacy and dignity of the residents. The fitting of appropriate door locks had enhanced privacy for residents in their bedrooms since the last inspection. One resident did comment that you could not have a private conversation on the pay phone, as it was located in the dining room. It is strongly recommended that a more private location be identified for this. Bethany CS0000016765.V180616.R01.doc Version 1.30 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 standard(s) 12, 13 and 15 There were no rigid rules or routines in the home and there were activities on offer however these did not meet with all resident’s expectations. Residents were able to maintain contact with families and friends. The meals in the home were good however there was little evidence of any choices being available or of medical diets being catered for. EVIDENCE: Residents spoken with confirmed there were no rigid rules or routines in the home and they were free to spend their time as they chose. Activities on offer included board games, bingo, ball and occasional visiting entertainers. Residents were observed wandering freely around the home, chatting in small groups, reading the newspaper, watching television and spending time in their bedrooms. Two residents commented they often go out with families, another that he attends a day centre twice a week and another that staff occasionally take her shopping. The residents spoken with had varying views of the activities in the home some saying the got bored others being quite content with what was offered. Residents confirmed they were able to have visitors when they wished and they were able to go out with their families. Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 12 The residents spoken with were generally happy with the catering arrangements at the home. The food records seen demonstrated varied and wholesome meals. Food stocks were plentiful and there was fresh fruit and vegetables available. Staff detailed to the inspector how they met the dietary needs of the residents that were diabetic however they needed to ensure this was reflected in the documented food records. The inspector was informed that the menus were being rewritten at the time of the inspection. The residents spoken with had no idea what they were having to eat for lunch or tea on the day of the inspection when asked what would happen if they did not like what was served they stated staff would find them an alternative. The menu needs to be displayed or residents consulted prior to meals as to their preferences, choices, likes and dislikes. Residents were able to have their breakfasts in their bedroom if they wished rather than having to go the dining room first thing in the morning. The dining room was pleasantly decorated and overlooked the garden area. Bethany CS0000016765.V180616.R01.doc Version 1.30 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 standard(s) These standards were not assessed during this visit however the requirement and recommendation from the previous inspection have been brought forward to this report and are in respect of written procedures and not the practices within the home. EVIDENCE: Bethany CS0000016765.V180616.R01.doc Version 1.30 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 standard(s) 19, 20, 21, 23, 24, 25 and 26. The standard of the environment within this home was good providing residents with a safe, attractive and homely place to live. EVIDENCE: There had been no change to the location or the layout of the home since the last inspection. It is accessible to all residents, safe and very well maintained by a permanently employed handyman. The home had a good standard of furnishings and fittings in the communal areas with the exception of some of the armchairs which were becoming visibly worn and needed to be replaced. All bedrooms had en-suite facilities of a toilet and wash hand basin. There were ample facilities throughout the home for bathing and showering some of which allowed for full assistance from staff. Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 15 All bedrooms seen were appropriately personalised and had good standards of décor and furnishings. There was evidence on the resident’s files that discussions had taken place with in relation to their requirements for the furniture in their room. The bedroom locks had been changed to a more appropriate type that allowed residents to lock their rooms but also that staff could access in emergency situations. The home was clean, hygienic and odour free with an appropriately located and equipped laundry. The main kitchen was very clean and tidy however it was noted by the inspector that there were some foods being stored in the fridge which had not been dated when opened. Bethany CS0000016765.V180616.R01.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Appropriate staffing levels were being maintained in the home with a stable staff group which was very good for continuity of care. EVIDENCE: There were 23 service users in residence at the time of the inspection and the staffing levels evidenced on the work planner for the week appeared appropriate. Staff at the home had a multi role that included caring, domestic, laundry and catering tasks. One person was being allocated daily to do the cooking and this was detailed. The home had managed to retain a core group of staff who had worked there for a considerable amount of time which was very good for the continuity of care. The inspector was informed there were no staff vacancies at the time of the inspection. All residents spoken with were positive in their comments about the staff group stating they were kind and helpful and there were some friendly relationships evident. Due to the manager not being in the home at the time of the inspection staff files could not be accessed therefore the requirements made in relation to training and recruitment following the last inspection have been brought forward to this report. Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 37 and 38. The manager was supported well by his senior team and provided clear leadership throughout the home. The health safety and welfare of the residents and staff were well maintained with only minimal requirements being made. EVIDENCE: Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 18 There had been no changes to the management of the home. The owner of the home was also the manager and he had many years experience of running the care home. Although not present during the inspection it was evident during discussion with both staff and residents that he set very high standards in the home and expected staff to adhere to these. He delegated responsibilities to senior care staff and, in turn, they delegated to care assistants and supervised their work. There was a need for further development of the care plans and risk assessments for residents. Health and safety were well maintained however there needed to be evidence that a fire drill had been carried out within the last six months and all documentation in relation to the servicing of the fire alarm and staff training in fire procedures needed to be available for both the inspector and any visiting fire officer. Accident and incident recording and reporting were seen to be appropriate. Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 2 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x x x x x 2 2 Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 17(2), 4(1)(a). Schedule 1 Requirement The manager must ensure that all the necessary information is collated for the statement of purpose for the home as detailed in Schedule 1 of the Care Homes Regulations. (Previous time scale of 01/08/04 not assessed for compliance.) The manager must ensure that the brochure is developed as the service user guide and that it contains all the information detailed in the National Minimum Standards. (Previous time scale of 01/08/04 not assessed for complaince.) All service users must be provided with a statement of terms and conditions of residence or contract at the point of moving into the home. (Previous time scale of 01/12/04 not assessed for complaince.) The manager must ensure that a full assessment is carried out prior to admission of any service users and that individual needs are detailed. (Previous time scale of 01/12/04 not met.) All service users must have care plans, that either they or their Timescale for action 01/07/05 2. 1 17(2) schedule 4(2) 01/07/05 3. 2 5(1)(b) 01/07/05 4. 3 14(1)(a) 01/07/05 5. 7 15(1) 01/07/05 Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 21 6. 7 13(5) 7. 7 13(4)(b) (c) 8. 9. 10. 8 9 9 12(1)(a) 13(2) 13(2) 11. 12. 9 14 13(2) 12(2) 13. 15 12(2) representatives have been party to, that set out in detail the action to be taken by staff to ensure all aspects of the health, personal and social care needs of the service users can be met and that are reviewed monthly. (Previous time scale of 01/01/05 not met.) All service users must have comprehensive manual handling risk assessments which detail the type of assistance required and the action to be taken by staff in the event of a fall. (Previous time scale of 16/11/05 not met.) All service users must have personal risk assessments which details all identified risks and how they are to be minimised. Where no risks are identified this must also be documented. (Previous time scale of 01/12/04 not met.) All service users must have nutrtional screenings and tissue viability assessments. There must be an audit trail for all medication. The amounts of PRN (as and when necessary) medication held must correspond with the amounts received and hose administered. Eye drops must be dated when opened and discarded after 28 days. The unsupervised use of the lift by residents should be risk assessed on an individual basis to ensure their independence is maintained as far as is possible. (Previous time scale of 01/12/04 not assessed for compliance.) daily menus must be displayed and residents consulted prior to meals as to their preferences, 01/07/05 01/07/05 01/07/059 13/05/05 13/05/05 12/05/05 01/07/05 01/07/05 Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 22 likes and dislikes. 14. 15. 15 18 17(2) Schedule 4(13) 13(6) The food records must include evidence hat medical diets are being catered for. The manager must develop a step by step adult protection procedure for staff to follow in the event or suspicion of abuse. (Previous time scale of 01/08/04 not assessed for complaince.) Any worn armchairs must be replaced. All foods stored in the fridge must be dated when opened. The manager must ensure that all appropriate checks are carried out on prospective employees prior to their commencing employment and ensure that all information as detailed in Schedule 2 of the Care Homes Regulations are available on site. (Previous time scale of 01/08/04 not assessed for compliance.) The manager must ensure that the induction and foundation training programme in the home is in line with the specifications laid down by TOPSS. (Previous time scale of 01/01/05 not assessed for compliance.) The manager must forward to the CSCI evidence that his qualifications are equivalent to NVQ level 4 in care and management. (Previus time scale of 01/04/05 not met.) The home must have a formal quality assurance system based on seeking the views of the service users and preferably audited externally. (Previous time scale of 01/08/04 not assessed for compliance.) The manager must ensure staff receive formal supervision at least six times yearly. (Previous 01/07/05 01/07/05 16. 17. 18. 20 26 29 16(2)(c) 13(3) 18(1)(a) & 19. Schedule 2. 01/08/05 12/05/05 01/07/07 19. 30 18(1)(a) 01/07/05 20. 31 9(2)(b)(i) 01/07/07 21. 33 24(1)(a) (b) 01/07/05 22. 36 18(2) 01/07/05 Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 23 23. 24. 38 38 23(4)(e) 23(4)(a) time of 01/01/05 not assessed for complaince.) There must be evidence on site 16/05/05 that a fire drill is carried out every six months. The documentaion in relation to 01/07/05 the servicing of all fire equipment and staff training in fire procedures must be available for inspection. 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 16 Good Practice Recommendations It is recommended that the copy of the complaints procedure on display is enlarged and displayed prominently and that all service users relatives or their representatives are asked if they would like a copy. (To be assessed at next inspection.) it is strongly recommended that the public phone is relocated to a more private area. 2. 10 Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 24 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor,Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Bethany CS0000016765.V180616.R01.doc Version 1.30 Page 25 - 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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