Inspection on 21/12/05 for Bethany

This inspection was carried out on 21st December 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bethany 27/09/07

Bethany 07/06/06

Bethany 02/06/05

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 Oliver Unannounced Inspection 11.00 21 December 2005 st X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 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 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) Bethany Care Trust Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 2005 Brief Description of the Service: The home is registered to provide care and accommodation 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 environment is built to a high standard. The garden is large and well maintained, providing additional recreational space. Bethany Care Trust is the registered provider for Bethany and service users are encouraged to retain their own privacy. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours. The acting manager was not available on the day of inspection but the staff on duty assisted with the visit. Many of the core standards were inspected during the previous visit on 2nd June 2005; therefore referral to both reports will give a full overview of the service. An opportunity was taken to look around parts of the home, view some records and talk to seven service users and four staff. Service users spoken to say how happy they were living at the home. Throughout the visit it was evident there is a relaxed and supportive atmosphere. Relatives were visiting the home on the day of the inspection but were not spoken to on this occasion. What the service does well: What has improved since the last inspection? Staff are now being encouraged to sign their training records once they have attended some training. This gives a clearer picture of what training has been undertaken. Regulation 26 visits are being undertaken regularly with a copy of the report being sent to the Commission. This demonstrates views of staff and service users are being sought and quality assurance is being undertaken. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 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 DS0000011636.V252541.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion as the core standards were inspected at the last visit and found to be satisfactory. EVIDENCE: Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The current policies and appropriate training in relation to medication are in place and protect service users. EVIDENCE: The home has a system in place whereby medication is packaged by the pharmacy into a dossett box and is then administered by the staff team. The relevant documentation is available including a detailed medication policy. Staff have completed medication training and the inspector saw the training records for this. It was a distance learning course over a six week period and staff spoken to said how useful the course was. There are some service users who are not able to tell staff when they are in pain and it was suggested that the care plan details how these service users show they are in pain. For service users who use ‘as required’ medication they have their own book and the medication used is recorded with a running total kept. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 10 Two service users currently self medicate and the relevant documentation is in place. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion as the core standards were inspected at the last visit and found to be satisfactory. EVIDENCE: Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 Arrangements for protecting service users and responding to their concerns is satisfactory. EVIDENCE: The head of administration stated they have received the new policy on safeguarding adults and other staff spoken to confirmed they have received the necessary training and are confident on the process. Although two staff had received the training this was not reflected in the records and the head of administration agreed to update the records. There have been no complaints and the procedure is available to all service users living in the home. Service users spoken to said all staff are approachable and they can go to any of them with any concerns or worries they may have. Staff spoken to were confident on what to do if there received a concern or complaint. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home was clean and hygienic. EVIDENCE: The home was clean and tidy on the day of the inspection. The home has a suitable laundry room with all the necessary equipment available including gloves and aprons. There is also a full time laundress. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 The home ensures that staff are competent, in adequate numbers and qualified with the relevant checks and recruitment practices in place to ensure service users are protected. EVIDENCE: The rota clearly indicates who is on duty with four staff in the morning and three on an afternoon and evening. There is also two staff on waking nights. The rota also indicates the kitchen staff, laundry staff, domestic staff and office staff. On the day of inspection there was adequate staff on duty. The inspector viewed four staff files and they contained all the relevant recruitment checks including application forms, references and criminal record bureau checks. The staff spoken to confirmed they have the skills to support service users including their experience of working in the field of older persons and the training they have attended including role of the care worker, principles of care and moving and handling. They also confirmed they receive regular supervisions. The records seen confirmed this and staff are starting to sign once they have received training. It was discussed with the head of administration that the relevant documentation needs to be in place to show staff have received abuse training. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 15 The head of administration said more work is needed to ensure staff have up to date inductions and this is being actioned including information being updated to reflect ‘Skills for Care’. The inspector will view this during the next inspection. However the home has a booklet for new staff that gives immediate information when they first start including the running of shifts, core values, the premises and information on moving and handling. Service users spoken to like the staff that support them and felt they had the skills to do the job and they trusted them. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35 The home is managed efficiently and service users benefit from a well run home. Service users views are sought to ensure they are involved in the selfmonitoring, reviewing and development of the home with their finances safeguarded. EVIDENCE: The registered manager has recently left and the acting manager has worked in the home for a significant period of time and has the skills and experience to manage the home. The Commission has been kept informed and the current management arrangement is under review. The Commission is just waiting for the information detailing the acting manager’s experience and qualifications. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 17 Additionally the administration person has been promoted to head of administration and has more responsibility especially in the area of record keeping. Staff and service users spoken to said the manager was approachable and was able to assist with any problems they may have. There are service user satisfaction questionnaires available and these are given to service users with their service users’ guide for them to fill out as needed. There is also one available for relatives or friends. The head of administration confirmed that as comments are received these are dealt with and the individual is informed of the outcome. The home is currently organising service user meetings as discussed during the last inspection. Regulation 26 visits are now being undertaken on a monthly basis and a copy is sent to the Commission. Service users are involved in these visits and this is documented. The home looks after fifteen service user’s monies but this is only for safekeeping and are not appointee for anyone. Each service user has a separate envelope with their money in and this is then kept in the safe in the office. There is also the relevant recording in place when money is received or taken out with receipts kept. It was discussed with the head of administration that it is good practice to encourage service users to sign if they are able whenever there is a transaction of their money so they are aware of what is happening. Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bethany DS0000011636.V252541.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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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