Inspection on 28/11/06 for Bethany House

This inspection was carried out on 28th November 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 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 31/10/05

Bethany House 11/05/05

Bethany House 02/11/04

Bethany House 19/05/04

Bethany House 12/02/04

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 434/436 Slade Road Erdington Birmingham West Midlands B23 7LB Lead Inspector Kulwant Ghuman Unannounced Inspection 28th November 2006 11:00 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 DS0000016765.V322212.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 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 DS0000016765.V322212.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethany Address 434/436 Slade Road Erdington Birmingham West Midlands B23 7LB 0121 350 7944 0121 624 7311 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) Mr Joseph Alphonse Rodrigues Mrs Helen Rodrigues Mr Joseph Alphonse Rodrigues Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Bethany DS0000016765.V322212.R01.S.doc Version 5.2 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. 31st October 2005 Date of last inspection 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 residents with a water fountain feature, raised flower beds and seating available. Access to the grounds is via the dining room and three bedrooms on the ground floor have direct access to the grounds. The fees at the home range from £314 to £420.26. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this key unannounced inspection over one day in November 2006. As part of the inspection a tour of the building was carried out, two staff were spoken with, seven of the twenty four residents were spoken with, four staff files and four resident files were sampled along with other care and health and safety documents. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. Two complaints had been lodged with the CSCI and these were looked into during this inspection. One was relating to the employment conditions for staff, particularly those from abroad. The matters referred to in this complaint referred to employment matters that were outside the remit of the CSCI, and issues such as the living conditions of overseas staff that did not contravene any regulations. The issues raised regarding residents could not be fully investigated at this point due to the passage of time since the original events. The other complaint was regarding the staffing levels in the home, meals, the suitability of where staff took breaks and staff having to use step ladders for cleaning tasks and the size and content of residents meals. Staffing levels appeared to meet the needs of the residents, staff were seen to take breaks within the communal areas of the home and staff were expected to step outside the home if they wanted to smoke. Staff used stepladders to dust at high levels. It was advised that extendable dusters were provided so that the use of ladders and the risk of accidents was reduced further. There was no evidence to support the fact that portions of food were small or that there was a lack of variety of vegetables. The inspectors were concerned to note that several of the requirements made at the last inspection had not been met and that the recruitment checks required by good employment practice and the Care Homes Regulations were not being undertaken before staff were being employed putting the residents at unnecessary risk of harm. Bethany DS0000016765.V322212.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: The manager needed to ensure that the admission process clearly identified visits to the home, the needs identified and how they were to be met. A review of the service being provided needed to be carried out 28 days after admission of a resident to the home. The care plans and risk assessments needed to be improved significantly to safeguard the residents. Any trends in weight loss or gain needed to be identified and referred to the particular professional for follow up. Privacy needed to be safeguarded for the residents and curtains on glass panels must be suitable to fulfil their role. The home needed to ensure that residents were informed and made aware of what was on the menu and what alternatives were available. Supper needed to be offered to residents. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 7 The manager needed to ensure that the safety of residents was safeguarded. The staff needed to have adult protection training, the procedures needed to be available to the staff, staff must not be employed before references and POVA checks are in place. Tablets of soap and nail brushes must be returned to bedrooms after use. Paper towels must be available in the communal washing areas. Staff needed to undertake induction training and the manager needed to ensure that it was completed within twelve weeks of employment. The manager needed to ensure that all staff had undertaken training to equip them to carry out their tasks. 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 DS0000016765.V322212.R01.S.doc Version 5.2 Page 8 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 DS0000016765.V322212.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,and 5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information was available to help residents decide on whether to move into the home, the majority of residents had received contracts but the pre-admission assessment was poor leaving the residents at risk of not having their needs adequately met by the staff. EVIDENCE: A service user guide and statement of purpose could be printed off the computer if required. Some residents could not remember if they had had a copy and some stated that their relatives had copies. Some amendments were needed in to the service user guide to indicate the range of fees charged in the home. The complaints procedure needed to ensure that anyone wanting to make a complaint were aware that they could raise the complaint with the Commission for Social Care Inspection (CSCI) at any point in the process. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 10 Four residents’ files were sampled for the presence of contracts. Three files contained a completed contract that indicated the room to be occupied, the fees to be charged and were signed by either the resident or their representative. One file did not include a contract. The pre-admission assessments were not signed or dated and did not identify where the assessment had been carried out. The pre-admission documentation did not allow for any level of detail to be recorded by the assessor. This documentation needed to be developed to allow for adequate information to be recorded so that the staff had sufficient information to know how to assist the residents. Three of the files sampled for the pre-admission assessment indicated that one resident was fairly independent and was mostly self-caring. The other two files showed that the pre-admission assessments were basic in the amount of information that was collected, for example, one resident was confused but there was no information about how this confusion was presenting itself and what strategies had been used to manage them in the previous home. None of the files identified whether a visit to the home had been carried out or the reason why this did not occur. Some residents stated that their relatives had visited the home before they moved in. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents medicines were administered as they were prescribed and safeguarded their health needs. The lack of detail and updating of care plans and lack of risk assessment left the residents as risk of not having their needs adequately met. EVIDENCE: Three residents’ files were sampled and showed a great difference in the level of information recorded in them. Some of the care plans had a good level of detail of what tasks could be done by the resident and what actions staff needed to take. The care plans were not updated as the needs of the residents changed. For example, one resident was fairly independent in terms of mobility but confused on admission. There were no details regarding how the confusion might manifest itself and how the staff were to respond to it. When the physical health of the individual deteriorated the details for providing personal care were very good however, Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 12 the personal risk assessments, moving and handling assessments and nutritional and pressure sore prevention assessments were not updated. As the individual’s health improved slightly and the assistance required changed this had not been reflected in the care plans and risk assessments. The risk assessments did not reflect this individuals needs, there was no indication of how the individual was being assisted to transfer. A member of staff spoken with stated that two members of staff stood either side and hooked their arms under the shoulders to carry out a transfer. This was poor moving and handling procedures and could lead to injury to the individual. There were no risk assessments for the use of bed rails or the reason for requiring them. During the day it was observed that the individual required a soft diet but this was not reflected in the care plan. The individual had been losing weight ever since admission to the home but there was no evidence that this issue had been picked up and raised with any professionals for investigation. Daily records for the individual indicated that on occasions a nutritional supplement was being given but again this was not identified in the care plan. For another resident there were some risk assessments in place however they did not indicate how the risks were to be managed. There was no evidence on the files sampled that a review of the service was being carried out 28 days after admission to the home. Records were kept of professional visitors to the residents and these included visits by GP’s, district nurses, chiropodists and dentists, however, there was a lack of consistency in transferring these visits from other books eg, chiropodist visits. The system for the administration of medicines was managed well. A blister pack system was in use and medicines were being administered according to the prescribing instructions. All audits carried out tallied except for one minor discrepancy. There were no controlled medicines in use at the home, no residents were self-administering medicines. The home’s contract stated that all residents must have their medicines administered by the home. Residents should be enabled to manage their own medicines if an assessment identified that they were able and compliance checks needed to be carried out on a regular basis to ensure that they were managing the medicines as required. Residents’ bedrooms had an appropriate lock on the doors and there was a lockable facility in the bedrooms. One resident who wanted the bedroom door kept locked had it locked but the staff kept the key in case it got lost. There was an agreement on the file to indicate that the resident was in agreement Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 13 with this. This should not be a general rule. Residents needed to be enabled to take risks and one of these could be that keys could be mislaid. Privacy was generally respected and privacy curtains were available in shared rooms, however, some poor practice was identified where staff were using a glass panel in a connecting door between two bedrooms to carry out night checks. This was not acceptable as it meant that residents could also look into the other bedroom. Staff needed to go into individual bedrooms if checks were required at night. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were no rigid rules in the home, visitors were welcomed, residents were encouraged to make some choices. Residents stated they were happy with the food provided however, they were not always aware of what was on the menu. EVIDENCE: There appeared to be no rigid rules in the home. Staff and residents confirmed that residents could get up and go to bed when it suited them. Some residents went out with their relatives but there were no regular outings organised by the home. Church services were held in the home and some residents went out with their relatives to church. Birthdays were celebrated as were main celebrations. Relatives and visitors were welcome to the home outside of meal times. There was evidence that there were some newspapers delivered to the home. Some residents stated ‘there was not much going on’ and ‘they tend to watch the television’. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 15 Residents stated that they enjoyed the food and there was plenty of it available. One resident commented that tea was a little early in the evening and they didn’t get anything after that. Activity records needed to include comments on who had taken part, who had refused and whether it had been enjoyed. There was a menu in place and this was mainly followed. The menu indicated that Tuesdays, Thursdays, Fridays and Saturdays the meals were set, however Sundays, Mondays and Wednesdays the menu changed depending on which week it was. For example, on Wednesday Week 1 and 3 it was faggots on the menu and during weeks 2 and 4 it was shepherds pie. An alternative lunch option was identified on the menu however, the food records showed that it was rare for anyone else to have the alternative. Some alternatives were identified and sometimes taken up at evening tea. The menu indicated very few cooked desserts were provided and there was a limited choice of menu for the residents requiring a diabetic diet. There was a choice of sterilised or fresh milk available. Food stocks appeared to be satisfactory. The lunchtime meal for the day of the inspection was roast lamb, mashed potatoes, mint sauce, gravy and peas; tinned fruit and ice cream. Ice cream and fresh fruit was available for residents on a reduced sugar diet. The variety of dessert for residents on a diabetic diet was very limited. No biscuits suitable for diabetics available in the home. In addition to the diabetic diets some residents were seen to be having a soft diet. It was pleasing to note that the portions of meat, potatoes and vegetables were kept separate. The home was advised that a large menu in the dining room may help residents know what was available at the mealtimes and that they should look at ways in which residents could be made aware of the choices available. Residents were able to bring some personal items into the home to personalise their bedrooms and able to sit in any of the three lounges or return to their bedrooms. It is advised that residents needed to be enabled to take some risks in their lives so that they could retain some of their independence. This could include areas such as holding keys to their bedrooms, being able to be administer medicines if a risk assessment identified that they were able to so. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The residents were not safeguarded by the recruitment procedures in the home, the adult protection procedures were not accessible to the staff and not all staff had undertaken adult protection training. EVIDENCE: Two complaints had been logged with the CSCI since the last inspection. One was relating to the employment conditions for staff, particularly those from abroad. The matters referred to in this complaint referred to employment matters that were outside the remit of the CSCI, and issues such as the living conditions of overseas staff that did not contravene any regulations. The issues raised regarding residents could not be fully investigated at this point due to the passage of time since the original events. The other complaint was regarding the staffing levels in the home, meals, the suitability of where staff took breaks and staff having to use step ladders for cleaning tasks and the size and content of residents meals. Staffing levels appeared to meet the needs of the residents, staff were seen to take breaks within the communal areas of the home and staff were expected to step outside the home if they wanted to smoke. Staff used stepladders to dust at high levels. It was advised that extendable dusters were provided so that the use of ladders and the risk of accidents was reduced further. There was no evidence to support the fact that portions of food were small or that there was a lack of variety of vegetables. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 17 These two complaints indicated that perhaps the relationship between the management team and the staff needed to be looked at to ensure that there was an opportunity for staff to raise issues of concern within the home before they found it necessary to go outside and that staff were reassured that their views would be taken into consideration. The staff generally record minor complaints and appropriate actions undertaken. The complaints procedure on display in the home, in the service user guide and in the contract needs to clarify that complaints can be lodged with the CSCI at any point. The residents were not aware of the complaints procedures but were generally aware that they could speak to someone if they were unhappy with things. This could be relatives or staff. There was a policy/procedure on adult protection in the home however this was not accessible to staff and the senior care was not aware of where to locate it. Staff had not all had training in adult protection. Recruitment procedures did not safeguard the residents and the manager had shown a disregard of the Care Homes Regulation by employing staff before undertaking any checks. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,20,22,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home was very good providing residents with a safe, attractive and homely place to live. EVIDENCE: No major changes had been made to the premises since the last inspection. The premises were clean, warm and well maintained with homely furniture. Communal areas consisted of 3 lounges including one used as a quiet lounge and a dining room with sufficient space for the residents. Propad cushions were in use on some easy chairs and there was one recliner chair for a resident. The fire doors to the lounges were wedged open. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 19 The rear garden area had been slabbed over to provide a seating area for residents. There was a fountain that the manager stated had been risk assessed and that residents were always supervised whilst they were outside. There were call points available throughout the home and there were adaptations available in the form of lift, stair lift, grab rails, assisted bathing facilities and ramped access into the home. Some bedrooms had pressure pads so that the staff were alerted if they get out of bed. There were a number of bathrooms available throughout the home allowing for assistance in some of them. All bedrooms had en-suite facilities consisting of a toilet and hand wash basin and there were additional toilets available in communal areas. Bedrooms seen were appropriately personalised and all bedroom doors had locks that enabled the residents to lock their bedrooms. There was screening available in shared rooms. There was central heating throughout the home and windows could be opened if required by the residents. The kitchen was found to be clean and fridge and freezer temperatures were recorded. One pack of lamb chops was past the use by date of 23.11.06 and one pack was not dated at all. All other foods dated on freezing. Tablets of soap and nail brushes were found in communal areas. Paper towels had run out in the shower room. One bath had not cleaned after use. One bath needed to be re-enamelled or changed as it was getting rusty around the plughole and stained. Hot water temperatures throughout the home were appropriate. The bottom of one freezer was rusting and although not affecting the temperatures would become increasingly more difficult to clean and keep hygienic. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The recruitment procedures did not safeguard the residents. Training records were not adequate enough to determine whether the staff were suitably qualified to undertake their roles. EVIDENCE: Staffing levels appeared to meet the needs of the residents. There were generally five care staff on duty during the morning and three during the afternoon. There were two waking night staff. There were no identified ancillary staff and care staff undertook the cleaning, laundry and catering. In light of the tasks needed to be undertaken by staff and the increasing levels of frailty of the residents the staffing levels must be reviewed on an ongoing basis and increased if required. The manager stated that he had employed two staff for whom the CRB’s and POVA’s were not in place. No reason for this given except that he knew they were good staff. He was aware that this was not the correct procedure but he was not expecting an inspection yet. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 21 There had been some turnover of staff since the last inspection with all the overseas staff having left. A core staff group remained that was good for the continuity of care for the residents. As stated above, the recruitment procedures were poor and did not safeguard the residents. However, the recruitment records for overseas staff included all the required documentation. This difference in recruitment practice could be seen as discriminatory with a tougher process in place for some staff. There was no written evidence of induction training however the manager stated that the staff were undertaking training equivalent to the Skills for Care training. The files for the four staff tracked indicated that some of them had been employed for more than 12 weeks and should have completed their induction. The staff-training matrix indicated that 6 of the 14 care staff had completed NVQ Level 2 training. It was difficult to determine whether the staff training was up to date as there were no dates on the matrix. Three of the four individual files indicated that the staff had not had any training but the fourth had had fire, health and safety and food hygiene training. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management of recruitment procedures, care planning and risk assessments must improve to safeguard the residents. Health and safety was well managed. EVIDENCE: The management of care plans and risk assessments was poor. The management of recruitment procedures were poor. The staff training records did not make clear that the staff had received the appropriate training within the required timescales. Two complaints lodged with the CSCI suggested that the relationship between some staff and the management team was not good as the issues related to the management of the home. The manager needed to ensure that staff were Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 23 reassured that they could raise issues and that their complaints would be listened to. All of the above issues indicated that the management of the home needed to be improved. There was no formalised quality assurance system in place. Staff meetings were held on a monthly basis and residents’ meetings 3 monthly. No audits based on the views of the residents or relatives were being carried out. The home did not hold any money on behalf of the residents and any expenses incurred in the home were invoiced to the residents. General health and safety was well managed with the required maintenance records in place. Fire records for alarms and emergency lighting were up to date, a fire drill had been carried out on 4.9.06. The fire officer’s requirements had been met but fire doors must not be wedged open. Checks for Legionella had been carried out. Gas, electrical, lift, stair lift, pat tests, bath hoists, call system and fire alarms had all been all serviced. Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 24 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 2 2 1 X 1 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 3 3 3 X 3 3 2 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 5(1) Requirement The service user guide must be updated to contain details of the range of fees charged in the home. All residents must be provided with a contract/terms and conditions of accommodation at the point of moving into the home. The manager must ensure that a full assessment is carried out prior to the admission of any resident and that individual needs are detailed. (Previous time scales of 01/12/04, 01/07/05 and 01/01/06 not met.) The admission process documentation must indicate when the assessment was carried out, where and by whom. The assessment documentation must cover all areas of need and provide sufficient space for adequate details to be recorded. Details of any pre-admission visit 01/01/07 must be recorded. Manual handling risk 01/01/07 assessments must include detail of the equipment and handling techniques to be used. (Previous time scales of 16/11/05, DS0000016765.V322212.R01.S.doc Version 5.2 Page 27 Timescale for action 01/02/07 2. OP2 5(1) 01/01/07 3. OP3 14(1)(a) 01/01/07 4. 5. OP5 OP7 12(1)(a) 13(5) Bethany 01/07/05 and 01/01/06 not met.) Staff must follow manual handling procedures at all times. Care plans must include 01/02/07 sufficient details for staff to know what tasks a resident can undertake and what assistance they require and how it is to be given. Care plans must evidence that the resident or their representative has been involved in drawing them up. Care plans must be reviewed and 01/01/07 updated as needs change. A review must be carried out 28 days after admission to ensure that the residents needs can be met by the home and that the resident is happy with the service being provided. Pressure risk assessments must include specific detail of the actions to be taken by staff to avoid pressure sores and detail any equipment to be used. (Previous timescale of 14/12/05 not met.) Risk assessments must be in place for all identified risks with strategies to manage them. Residents losing or gaining weight unintentionally must be referred to the GP or dietician to have this change in weight investigated. The home must develop a selfadministration medication policy. The manager must ensure that the privacy of residents is maintained at all times. The home should consult the DS0000016765.V322212.R01.S.doc 6. OP7 15(1) 7. OP7 15(2) 8. OP8 12(1)(a) 14/01/07 9. 10. 11. Bethany OP9 OP10 OP12 13(2) 12(4)(a) 16(2)(n) 01/02/07 01/01/07 01/03/07 Page 28 Version 5.2 12. OP15 Sch3(3) (m) residents on activities they would like on a group and individual basis. The residents must be consulted 01/03/07 about supper and records maintained of food offered and taken up by residents. The home must look into ways in which the residents are made aware of the alternatives available at mealtimes and what the choices are for each day. Food records must identify any special diets being provided. There must be a greater variety of dessert and biscuits available to residents on a reduced sugar diet. The complaints procedure needed to make clear that a complainant could raise a complaint with the CSCI at any point in the process. The policy and procedure on adult protection must be kept accessible to staff at all times. All items in the freezer must be dated on freezing and used by the use by date. Tablets of soap and nail brushes must be removed from communal washing facilities after use. Paper towels must be available in all communal areas. At least 50 of the care staff 01/04/07 must be trained to NVQ level 2 or equivalent. Two references must be obtained 01/01/07 for staff prior to their commencing their employment. (Previous timescale of 14/12/05 not met.) DS0000016765.V322212.R01.S.doc Version 5.2 Page 29 13. OP15 Sch 4(13) 01/02/07 14. OP16 22 01/02/07 15. 16. OP18 OP26 13(6) 13(3) 01/01/07 01/01/07 17. 18. OP28 OP29 18(1)(a) 19(1)(a) (b) Sch 2 Bethany No staff must be employed before references and POVA first checks have been received. Recruitment processes must be consistent regardless of the country of origin of the staff. There must be records maintained of the initial induction training staff receive when commencing their employment. (Previous timescale of 01/12/05 not met.) 19. OP30 18(1)(a) 01/01/07 20. OP30 18(1)(c) (i) The manager must ensure that staff complete their induction within 12 weeks of taking up employment. The manager must ensure that 01/04/07 all staff have undertaken training to equip them to carry out their role, including adult protection training. The training matrix must evidence that staff have undertaken the required training and regular updates. The home must have a formal quality assurance system based on seeking the views of the residents. (Previous time scales of 01/08/04, 01/07/05 and 01/02/06 not met.) Fire doors must not be wedged open. 21. OP33 24(1)(a) (b) 01/04/07 22. OP38 23(4)(c) (i) 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Bethany Refer to Good Practice Recommendations DS0000016765.V322212.R01.S.doc Version 5.2 Page 30 1. Standard OP12 It was strongly recommended that the activity records were developed to include comments from the residents on their suitability and include who had declined to take part. Residents should be enabled to take risks as assessed within a personal risk assessment. The manager should look at either replacing the rusting panel in the freezer or budget for a replacement freezer. It is recommended that supervision records are developed to include some of the comments made by both supervisor and supervisee. (Not assessed at this inspection.) It is recommended that staff are provided with extendable dusters to limit the use of ladders and reduce possible risk. 2. 3. 4. OP26 OP36 OP38 Bethany DS0000016765.V322212.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 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. 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