Inspection on 02/06/05 for Bethany

This inspection was carried out on 2nd June 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

Bethany 27/09/07

Bethany 07/06/06

Bethany 21/12/05

Bethany 06/12/04

Bethany 11/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Bethany Pamber Heath Road Tadley Basingstoke Hampshire, RG26 3TH Lead Inspector Debbie Hawkins Unannounced 11.00am 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 H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bethany Address Pamber Heath Road Tadley Basingstoke Hampshire RG26 3TH 0118 9701710 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) Bethany Care Trust Mrs Doris Butler CRH 37 Category(ies) of OP Old age - 37 registration, with number of places Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6th December 2004 Brief Description of the Service: Bethany Care Trust is the registered provider for Bethany and Mrs Doris Butler is the registered manager. The home is registered to provide care and accomodation to 37 elderly christians from various assemblies of gospel halls around the country. Bethany is a large detached property set in spacious grounds in Pamber Heath, Tadley. The physical envrionment is built to a high standard. The garden is large and well maintained, providing additional recreational space. Bethany encourages service users to retain their own privacy and supports them in any way they can. Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over six hours and as the manager was away on holiday the acting manager, and all other staff on duty assisted the inspector. An opportunity was taken to look around parts of the home, view some records and talk to service users, staff and visitors. The inspector spoke with seven service users and four staff. The inspector was also able to talk with some of the trustees. What the service does well: What has improved since the last inspection? What they could do better: Some service users spoken to said they would benefit from regular service user meetings and invite the cook and some of the trustees on occasions. It was discussed with the responsible individual that the regulation 26 records should be sent to the Commission every month and not send them all every six months. Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 6 Staff should be signing in their training records to say they have received the relevant training. 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 H54 S11636 Bethany V229764 020605.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 H54 S11636 Bethany V229764 020605.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 and 6 The home has a system of assessment, which identifies prospective service user’s needs and how they will be met. EVIDENCE: Each service user in the home has a detailed assessment and the inspector viewed three of these. This information is then transferred to the care plans allowing staff to see how each service user should be supported. Staff spoken to were able to demonstrate clearly, service user’s needs such as leg ulcers and those at risk of falls. The home does not offer intermediate care. Bethany H54 S11636 Bethany V229764 020605.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 and 10 Service user’s health, personal and social care needs are set out in an individual plan of care to adequately provide staff with the information they need to satisfactorily meet service user’s needs. Service users are treated with respect and their privacy is upheld at all times. EVIDENCE: Individual plans of care are available and give detailed information to ensure all aspects of health, personal and social care needs are met. These were all up to date with regular reviews taking place. It was discussed with the acting manager that for the newest person whose care plan was seen there could be more detail regarding how they are assisted with their weekly bath such as they require support to get in and out of the bath and not necessarily to assist with all aspects of bathing. Each service user has a moving and handling assessment and this is fully updated to ensure staff are aware of any necessary risks and how these can be minimised. Since the last inspection the care plans reflect all care needs and explain how these will be met. The information is now more consistent with staff writing more clearly and concisely in the daily diaries. Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 10 Risk assessments are also in place with regular reviews present. Staff spoken to were fully conversant with each individual’s care plans and risk assessment and confirmed they were regularly viewed and updated. One service user spoken to confirmed they do look at their care plans on occasions and when discussed with them agreed it was a fair indication of their needs. Service user signatures or that of their relatives were seen on other care plans. Service user’s health needs are also fully met with it being noted in plans that some service users receive regular chiropodist visits. The service user confirmed this. Service users spoken to said they visit their GP’s as needed or GP’s visit them at Bethany. They also have access to Opticians and district nurses as needed. One service user also had restrictions in place and the relevant documentation was available. It was evident throughout the visit that service users are respected and their right to privacy is upheld. Staff call service users ‘Mr’ and ‘Mrs’ unless they are requested otherwise and service users confirmed staff always knock on their bedroom doors and await permission before entering. One couple was seen making their own cups of tea for themselves and their visitor in the smaller lounge upstairs. One service user said there is a really good staff team in the home that are helpful and respectful. ‘I can go up to my room whenever I please for some privacy’. All staff are also aware that service users are encouraged to do as much for themselves as they are able so as to keep their independence. Bethany H54 S11636 Bethany V229764 020605.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, 14 and 15 Service users experience a stimulating and varied life at the home with visitors encouraged. Various informal activities are made available. They are assisted to exercise choice and control over their lives but more regular service user meetings would assist this further. The home has a balanced and varied selection of food available that meets service user’s tastes and choice. EVIDENCE: It is clearly detailed in care plans what service user’s particular interests are and service users spoken to confirmed this. Each service user has a social activity plan and this details what activity each person has undertaken during the month including singing, going on an outing, reminiscence and story reading. The home also has a lot of activities relating to religion, as this is the nature of the home. On the day of the visit the inspector viewed a game of carpet bowls being played, which service users were really enjoying. Many service users receive many visitors and this was evident on the day of the inspection. The inspector spoke with some relatives who were very happy Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 12 with the home and had no concerns or worries. There are no restrictions on visiting and they were seen visiting throughout the day. In respect of day to day aspects of their lives service users confirmed they are able to make choices, this includes when to get and what to wear. One service user says they requested they have a bath at 9 at night and this has been fully adhered to. However some service users spoken to said they would benefit from regular meetings to be able to discuss issues such as the food and the activities in the home, this was passed on to the acting manager. The inspector joined the service users for lunch and service users commented on how fresh the food was with much variety. One service user did express dissatisfaction with the choice at tea- time but has discussed this with the manager and this was resolved quickly and efficiently. During lunch there was a pleasant atmosphere with positive interaction between staff and service users. Service users were offered choices for their meal, dessert and whether they preferred tea or coffee. The menu was displayed on the white board in the dining room and offered choice. Service users spoken to said they have three meals a day and are offered an alternative if they don’t like what is on the menu. Bethany H54 S11636 Bethany V229764 020605.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) 16 and 18 Arrangements for protecting service users and responding to their concerns are satisfactory. EVIDENCE: The home has a detailed and relevant complaints procedure available in the office. Staff spoken to had a clear understanding on what to do if a service user complained to them. One service user spoken to had made a complaint and felt this was resolved quickly and efficiently. Another service user said they would approach the manager if they had any concerns. Staff confirmed they have received training in abuse and the newer staff are booked to attend and everyone spoken to would know what to do in the event of an allegation of abuse being reported to them. The paperwork to confirm this was seen. Since the last inspection the home has improved the house policy relating to adult protection and this now includes that social services are called in the first instance and to ensure the individual is safe. The flowchart from the Hampshire Adult Protection policy has been adapted for the home and is now accessible to staff. Bethany H54 S11636 Bethany V229764 020605.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 and 24 A comfortable and safe standard of accommodation is provided for the service users, which meet their needs. EVIDENCE: The inspector viewed the home and it continues to be well maintained and suited to the service users’ needs. It is decorated to a standard that creates a comfortable and homely ambience. There is a maintenance man employed to ensure the home is safe and respond to any issues around the home. Staff and service users spoken to were happy with the environment and expressed no concerns. The inspector also visited one service user in their bedroom, this offered plenty of space and individuals’ possessions were present. The service user was very happy with their bedroom especially the amount of room they have. Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 15 Bethany H54 S11636 Bethany V229764 020605.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) 30 The home has a good match of well qualified staff offering consistency of care within the home. EVIDENCE: The inspector sampled three staff training files and they showed full and varied training being undertaken specific to the service users living in the home. These include whistle blowing, adult protection, training in supporting someone with a leg ulcer and moving and handling. Additionally there are ten staff in the home that have either completed or working towards their National Vocational Qualifications (NVQ). It was discussed with the acting manager that staff should sign to say they have completed the training. Many staff working in the home have many years experience within this field of work. Also the home has had an influx of new staff requiring additional support but working well in the home. The inspector spoke with a new member of staff who confirmed they are settling in well and the full induction assisted with this. They have also had training in moving and handling and health and safety and are booked to attend training on abuse. Visitors spoken to said the staff are friendly, courteous and always welcoming. Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 17 Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 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 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) 38 The health, safety and welfare of service users is fully promoted with staff being well trained and showing a sound knowledge within the areas of health and safety. EVIDENCE: Policies and procedures relating to health and safety are available in the home and staff spoken to knew where and how to access them and had a satisfactory understanding of health and safety. Staff have also received the relevant training in areas such as infection control, fire safety, and food hygiene, the records for this were seen. Staff have now received fire training twice in a twelve month period. One staff member spoken to said everything relating to health and safety is dealt with by the handy man, another was very clear on what to do if they saw any hazards. Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 19 Staff confirmed there are the relevant records and certificates in place to ensure the environment is safe and secure, this includes portable appliance testing and fire equipment testing. Since the last inspection the home has now reviewed the risk assessment for the building. On the day of the visit the home was safe and free from hazards and the assisted baths were being serviced. Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x x STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 21 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. 1. 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. 1. Refer to Standard Good Practice Recommendations Bethany H54 S11636 Bethany V229764 020605.doc Version 1.30 Page 22 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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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