Inspection on 26/01/06 for Bethany

This inspection was carried out on 26th January 2006.

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 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 09/01/07

Bethany 14/09/05

Bethany 08/02/05

Bethany 12/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bethany Clarendon Place Leamington Spa Warwickshire CV32 5QN Lead Inspector Patricia Flanaghan Unannounced Inspection 26th January 2006 11:45 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 DS0000004211.V283596.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000004211.V283596.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bethany Address Clarendon Place Leamington Spa Warwickshire CV32 5QN 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) 01926 423661 01926 433041 bethany@cch-uk.com Christadelphian Care Homes Mr Alan Taylor Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2005 Brief Description of the Service: The home provides places for up to 21 individuals or couples who are members of the Christadelphian Church and who may be drawn from all parts of the country. The home provides residential care for older people and does not provide nursing care. Accommodation is spacious with individual rooms, which are equipped with a small kitchenette. There are care staff on duty 24 hours a day to provide personal care. Main meals, social activities and in particular bible readings are shared in the home, the local community and, with regard to church services, at a nearby sister home. Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place between 11.45am and 4.00pm. This was the second visit of this inspection year. Discussions took place with residents, staff and managers. The inspection focused on the standards relating to medication, health and safety, staffing and management. What the service does well: What has improved since the last inspection? 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 DS0000004211.V283596.R01.S.doc Version 5.1 Page 6 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 DS0000004211.V283596.R01.S.doc Version 5.1 Page 7 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 at this inspection. Standards 1, 3, 4 and 5 were assessed as met at the inspection visit on 14/09/05. EVIDENCE: Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 8 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 medicine management within the home was satisfactory but further improvements must be made to demonstrate that the resident’s needs are fully met. EVIDENCE: Audits demonstrated that the medicines administered from the Monitored Dosage System (MDS) supplied by the community pharmacist are administered and recorded correctly. There was evidence of good stock control. The following issues were identified and discussed with the manager. The home’s medication policy requires updating to reflect current good practice. For example, it didn’t address medication for residents who are out of the home for holidays/visits, drug errors, or PRN medication. The home did not routinely record the quantities of medicines dispensed in boxes and carried over from previous cycles so it could not be demonstrated that these medicines had been administered as prescribed. Medications transcribed by hand had not been initialled by staff. Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 9 PRN medications did not consistently record the number of tablets given, for example, when the amount of medications can be one or two it should be recorded how many tablets were administered to the resident. Verbal dose changes had not been documented appropriately on the MARs. Controlled drugs were checked and records were found to be accurate. Appropriate procedures and facilities were in place to facilitate those residents who wish to continue to administer their own medication. The manager has confirmed since the inspection visit that a medications returns book has been obtained and all unused or unwanted medication is being returned to the supplying pharmacist. Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 10 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 at this inspection. Standards 12, 13, 14 and 15 were assessed as met at the inspection visit on 14/09/05. EVIDENCE: Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 11 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): None of these standards were assessed at this inspection. Standards 16 and 18 were assessed as met at the inspection visit on 14/09/05. EVIDENCE: Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 12 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): None of these standards were assessed at this inspection. Standards 19, 20, 23, 24, 25 and 26 were assessed as met at the inspection visit on 14/09/05. EVIDENCE: Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 13 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): 28 and 29 The recruitment procedure ensures that suitable people are employed to safely provide care for the residents. A strong commitment to training ensures staff have the knowledge and skills to undertake their duties. EVIDENCE: Training records examined show that staff have attended regular training on the conditions associated with old age. Seven care staff have an NVQ Level 2 in Care, with two staff members currently undertaking this award. The staff files of two recently appointed staff were reviewed and indicated that the registered manager has completed all necessary recruitment checks to ensure the protection of service users. Evidence of new staff receiving a clear induction programme was available on the files. Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 14 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): 33, 35 and 38 Systems are in place to monitor the quality of the service provided and identify areas in need of improvement. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Residents and relatives expressed positive comments about the manager and were happy with the way the home is run. An open door policy for residents and relatives is practised. Relatives spoken with stated that they found the managers, care staff and other staff in the home approachable. The quality of the service is continuously monitored through feedback received from the residents and their relatives. Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 15 The manager said that every resident received an annual questionnaire that sought their opinion of the care and service they had received. An analysis of the results was then made available. The result of the survey undertaken in December 2004 was viewed. The manager advised that a further survey is now due. Regular residents meetings are held and the minutes of the meeting held on 09/01/06 was viewed. There was evidence that the manager acts on any issues raised by the residents at these meetings. The majority of residents in Bethany manage their own finances and the home holds monies for only one resident in the home. This is handled in line with the homes policy of handling resident’s money, ensuring their financial interests are safeguarded. The account was checked at the inspection visit and found to be satisfactory. Evidence was seen to confirm that staff receive regular training in moving and handling, fire safety, first aid and food hygiene. Certificates were seen during the inspection for the maintenance and service of major systems. No health and safety hazards were observed at this inspection. Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 16 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 2 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 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 17 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 OP9 Regulation 13(2) Requirement The quantities of all medicines carried over from previous MAR charts must be recorded to enable audits to take place to demonstrate medicines are administered as prescribed. All hand written MAR charts must accurately record all the medication the service user has been prescribed, the strength of the medicines and the correct dose. A competent person should countersign all entries. The medication policy must be reviewed to reflect good practice in medicine management. Timescale for action 30/04/06 Bethany DS0000004211.V283596.R01.S.doc Version 5.1 Page 18 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 DS0000004211.V283596.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 DS0000004211.V283596.R01.S.doc Version 5.1 Page 20 - 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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