Inspection on 07/06/06 for Bethany

This inspection was carried out on 7th June 2006.

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 21/12/05

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 Keith Hopkins Unannounced Inspection 7th June 2006 10:30 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.V293886.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 DS0000011636.V293886.R01.S.doc Version 5.1 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 To be Confirmed Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21/12/05 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 of a high standard, with large attractive communal areas and the majority of bedrooms being single. 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. Fees range from £440 to £ 595 per person per week. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Six and a half hours were spent visiting the home, during which time the opportunity was taken to look around the home, view records and policies and to talk to the head of care and the head of administration. The manager’s post is currently vacant. The inspector also spoke privately with two members of the care staff and the chef. Most of the service users were observed making use of communal areas and their bedrooms and a number were spoken with briefly. Four service users were spoken with at greater length in the privacy of their bedrooms. What the service does well: What has improved since the last inspection? Facilities available for service users have been improved through the addition of an extension to a lounge providing further opportunities for socialising and mixing with others. Service users’ enjoyment of the garden has been enhanced through the addition of an aviary and further seating areas Bethany DS0000011636.V293886.R01.S.doc Version 5.1 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.V293886.R01.S.doc Version 5.1 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.V293886.R01.S.doc Version 5.1 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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has assessed the needs of its current service users well. These needs are clearly recorded and known to staff. EVIDENCE: Four service users’ files, one relating to a more recently admitted person, were inspected and needs assessments seen within these files contained a good level of detail. One service user confirmed that his needs were being met by the home after he had himself arranged to move in. There was clear information regarding the way in which health, social and personal care needs were to be met. The initial assessment is undertaken prior to the person concerned being admitted. The inspector also saw evidence that assessments were reviewed, and service users spoken with confirmed their involvement in the review process. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 9 Staff spoken with were clearly aware of the needs assessments. The chef, for example, explained the need to provide a ‘soft’ diet for those service users assessed as needing this. The home does not admit service users for intermediate care, although one service user who had lived at the home for some time explained to the inspector that he was looking forward to moving out of the home into his own accommodation and had been assisted by staff at the home in achieving this. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 10 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): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good care planning regime which addresses identified personal, social and health care needs and involves service users. EVIDENCE: Four care plans were examined and contained information for staff to ensure that all aspects of health, personal and social care needs could be met. Plans are reviewed on a regular monthly basis and service users confirmed their involvement in this process. Service users also said that staff knew how to help them with their personal care needs and did this with dignity and respect. Plans contained information regarding more specific needs such as chiropody and dentistry. Some service users, for example, access these services externally rather that ‘in-house’. Service users have a choice of doctor from within the local surgery and one service user confirmed that following a recent Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 11 consultation with a doctor arrangements were in hand for him to see a specialist. The home has a policy and procedure for dealing with medication, which enables service users to exercise choice over whether they wish to deal with their own medication. Two service users are currently doing this and risk assessments were in place regarding this. Secure facilities are available for these persons. One service user commented that he was happy for the home to deal with his medication. The drugs cupboard, including the separate controlled drugs cabinet, was secure at the time of the inspection and the inspector was informed by the head of care that no drugs currently needed to be refrigerated. Staff responsible for dealing with medication have been trained. Records relating to two service users were examined. On one occasion it appeared that a service user had chosen to take a painkilling tablet which had been prescribed on an ‘as necessary basis‘ but that this had not been recorded. The head of care agreed to investigate this omission. One service user commented that there was ‘a nice group of staff’ and another that the ‘chef was good’. Staff were observed to be providing assistance to service users in a calm and dignified manner, and knocked on doors, awaiting a response, before entering. Service users’ wishes regarding the way in which they are addressed by staff are recorded in their care plan and respected by staff. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 12 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): 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy varied lifestyles and undertake activities of their choice. Visitors to the home are encouraged. Service users enjoy attractively presented meals in congenial surroundings. EVIDENCE: Care plans clearly detail what each service user’s interests are and service users themselves confirmed, variously, that they enjoyed activities such as reading and going out on trips. A number of service users had, that morning, gone out in the home’s minibus, and other service users confirmed that they had gone shopping. The inspector observed that books were available and one service user confirmed that he took a daily newspaper. The nature of the home means that there are various religious activities arranged and the head of care confirmed that some of these took place in the community. Service users also had the opportunity to watch videos and to do puzzles. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 13 The inspector was not able on this occasion to speak with any visitors to the home, who are encouraged to visit as they wish. A separate room is available which service users confirmed could be used to entertain visitors as well as bedrooms or other communal areas if this was preferred. Service users are able to move freely around the building and one service user informed the inspector that the gardens to the home could also be freely used and were readily accessible. Service users were able to use their bedrooms during the day if they wished and a number preferred to do this. Menus at the home were varied and the inspector observed an attractively presented meal being served in the dining room at lunchtime. One service user confirmed that the food was good and that choices were available at breakfast time and teatime, with an alternative to the midday meal being offered if need be. Service users are encouraged to take meals communally in the dining room but may use their own rooms if they wish. The chef was clearly aware of individual needs and choices and explained that although no special diets were currently needed, these had in the past been provided when necessary. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 14 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 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure, which service users are aware of and feel able to use. Service users are protected through an adult protection policy and procedure known to and understood by staff. EVIDENCE: The home has a complaints policy and procedure, a copy of which was included in the service users guide. A copy of this guide was kept in each bedroom at the home so that service users had ready access to it. All service users spoken with privately said that they had no complaints and were aware of what to do if they had. Service users all appeared to have a good degree of confidence that any issues raised would be dealt with, although it was reported that the home had had no complaints to deal with in the previous 12 months. Staff when interviewed said that they would let the team leader know if any service users complained to them. The home also has a policy and procedure relating to adult protection, with information produced by Hampshire Social Services being available for staff to consult. Staff have been trained in this and when interviewed confirmed their understanding of what to do in the case of suspected abuse. Staff showed the inspector a copy of the video, which had been viewed by them as a part of this Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 15 training. Both members of staff interviewed said that they would report anything they needed to. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 16 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): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and comfortable environment, which is suitably furnished, well maintained and meets residents’ needs. EVIDENCE: The tour of the building showed this to be clean and tidy throughout and there were no undue odours. Communal areas were well furnished and adequate bathroom and toilet facilities with aids were available. Communal areas include a separate room where visitors may be entertained and a flat where visitors may stay overnight if need be. The inspector visited four service users in their rooms, which were all adequate in size, and had clearly been personalised, to considerable degrees. Comments made variously by service users included that it was ‘a nice building’, and that Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 17 the home was ‘spacious’, with one service user saying that he was ‘pleased with the room’. Service users were observed to be freely making use of communal areas, such as the lounge and other communal areas and accessed their bedrooms as they wished. The home’s laundry was inspected and was fit for purpose with machines being automatically fed with detergent. The member of staff responsible for the laundry was clearly aware of good practice and there were procedures in place to deal with soiled items. Gloves and aprons were available. The building is well maintained with a full time maintenance person to deal with day-to-day matters. A repairs book is used to detail any items requiring attention. The inspector saw the newly created area adjoining the lounge on level one which service users may use to relax in, and also observed the attractive grounds available to service users which it is understood have recently been enhanced through the addition of an aviary. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 18 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, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are appropriately trained and are employed in sufficient numbers to meet service users’ needs. Service users are protected through the soundness of the home’s recruitment practices. EVIDENCE: The inspector examined three staff files, one relating to a more recently appointed person. These contained evidence of written references being obtained following the completion of an appropriate application form and interview. There was evidence of Criminal Record Bureau (CRB) disclosures having been obtained. Staff have job descriptions and there was evidence in files of an initial performance review having taken place following a new member of staff’s initial period at the home. A more recently appointed staff member confirmed that ‘shadowing’ a more experienced person formed a part of her induction programme. Files contained evidence of the various short courses undertaken which included First Aid, Basic Food Hygiene, Fire Safety, Moving and Handling, Safe Handling of Medicines and Care of Ageing Skin. The home has a training plan and future courses planned for the year include Continence Promotion and Control of Substances Hazardous to Health (COSHH). Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 19 Staff files examined confirmed the home’s supervision and appraisal system, staff being supervised every other month with a more formal appraisal twice a year. During the inspection the inspector observed staff members interacting with service users in a friendly yet professional manner. It was explained to the inspector, and confirmed by the rota, that there were usually three members of care staff on duty in the mornings and three in the afternoons who were backed up by ancillary staff. There are two members of staff on waking duty at night. Staff were observed to be attending to service users’ needs in a calm and unhurried manner, although said that they were busy at times. Service users without exception commented positively about staff saying variously that ‘nothing is too much trouble’, that the ‘staff are wonderful’ and that ‘staff know how to attend to my personal needs’. One service user said that staff came immediately when he had an accident. It is understood that almost 50 of the care staff have a National Vocational Qualification at Level 2 and that two further staff are undertaking this. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 20 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, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements are in hand to ‘cover’ the current manager’s vacancy and there are comprehensive policies in place to support staff, although there needs to be an application for the registration of a manager made at the earliest opportunity. EVIDENCE: The inspector was informed by the Chairman of the Trustees that action was being taken to address the current vacancy for a manager. The home is currently being managed by the head of care who has worked in the home for a significant period of time and who is well supported by the head of administration. The inspector noted that several letters had been received over a number of years complementing the home. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 21 A Residents Meeting, attended by some 20 service users, had been held on the 8th February 2006, and it was subsequently noted that action had been taken regarding suggestions made at the meeting. There was a survey of service users undertaken in January 2006, with it being confirmed that as comments are received these were dealt with. It is understood that all new service users are given a satisfaction questionnaire as a part of the home’s admission procedure. The home provides a safekeeping facility for service users who wish to make use of this. Monies being held for two service users were examined and associated records and receipts tallied correctly with these monies. The home has a policy for the control of substances hazardous to health known to staff. Chemicals and other items were securely stored in locked cupboards and staff were aware of health and safety issues. The home has a health and safety policy known to staff. The water at a hot water outlet accessible to service users was checked and was not unduly hot. A sample of policies, procedures and records required by regulation were inspected and were in order and up to date. This included the home’s fire records and accident book. Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 22 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 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 23 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.V293886.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Hampshire Office 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. Extracts may not be used or reproduced without the express permission of CSCI Bethany DS0000011636.V293886.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!