Inspection on 05/06/07 for Bethany Christian Home

This inspection was carried out on 5th June 2007.

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 Christian Home 14/12/05

Bethany Christian Home 07/06/05

Bethany Christian Home 19/11/04

Bethany Christian Home 02/06/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Bethany Christian Home 2 Woodside Lipson Plymouth Devon PL4 8QE Lead Inspector Jane Gurnell Unannounced Inspection 5th June 2007 09:15 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 Christian Home DS0000003471.V336014.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 Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethany Christian Home Address 2 Woodside Lipson Plymouth Devon PL4 8QE 01752 220692 01752 220692 bethanyhomepl4@btopenworld.com 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 Christian Home Trust Miss Ann Laidler Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users Aged 60 Date of last inspection 14th December 2005 Brief Description of the Service: Bethany Christian Home is a large detached house, set in its own grounds in a residential area of Lipson, close to local amenities, public transport links and a public park. The home is run by a Christian organisation and there is a daily Christian worship service. However, the admission policy for the home is not exclusive. The home is registered to provide accommodation and personal care for 26 residents over the age of 60. The home does not have the specialist categories of either DEE (Dementia Elderly) or PDE (Physical Disability Elderly). Accommodation is provided over 3 floors and comprises of 2 lounges, 2 dining rooms, 2 conservatory areas, and 22 bedrooms, two of which are double rooms. Planned building work has reduced the number of bedrooms but this will increase once completed to provide 26 single bedrooms. There is an annexe to the rear of the building, containing 4 of the single rooms. The annexe offers more semi-independent accommodation. A shaft lift provides access to all rooms in the main building. The home offers 3 bathrooms, two with assisted baths and one with a walk in-shower, all are suitable to be used by people with restricted mobility. Many of the rooms have views over Plymouth Sound and others overlook a public park. The people living at the home are enabled to access any health or social care services they require and various social activities are arranged by the home. The garden is attractive, spacious and accessible. The current weekly fee for the home is £355. Items not included in the fee include chiropody treatment, hairdressing, newspapers and magazines and personal toiletries. Information regarding the services provided at Bethany Christian Home can be obtained directly from the home. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken on 5th June 2007. Miss Laidler, the Registered Manager was present throughout. The inspector spoke to each of the people living at the home about their experiences, as well as the staff on duty and the Registered Manager. A tour of building was made and documents relating to the care of people, employment practices and the general running of the home were examined. What the service does well: What has improved since the last inspection? The Bethany Christian Home Trust has invested heavily in the home over the past year. A shower room has been created that provides a comfortable shower chair and ample space for staff to assist people with restricted mobility. Two bedrooms have been upgraded to provide en suite facilities. A hallway has been made next to the laundry room so that those people living in the annex are no longer required to walk through the laundry to access the main house. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 6 A new car parking area has been created in readiness for the extension from the annex into the existing car park. The practice of secondary dispensing medicine from the packaging in which it was prescribed into named pots has been changed to a measured dose system prepared by the local pharmacist that reduces the risk of medication errors occuring. 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. The summary of this inspection report can be made available in other formats on request. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 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 Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thorough and comprehensive systems for admission allows people considering moving into the home and their relatives to be confident that their needs can be met. EVIDENCE: Two newly admitted people to the home said they had been provided with written information describing the services at Bethany Christian Home prior to their admission and they had been invited to spend time in the home before making any decision. They said they had participated in an assessment of their care needs and this was evident in their documentation. Both people said they already knew the home prior to their admission through visiting friends and church members who were already resident. They had decided some time prior to their admission that they wished to move into this home when they were in need of residential care themselves. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of the people living in the home are being met and people are treated with great respect. Medication practices are safe. EVIDENCE: The inspector spoke to all of the people living in the home: all were full of praise and said they felt very well cared for by kind and caring staff. They said they could ask for assistance at any time and nothing was too much trouble. The home was described as “excellent” and many people said that they could not find fault. They particularly commented upon the pleasant and happy atmosphere, their relationship with the staff and the Christian environment. The inspector spent time observing the daily life in the home and found the staff had a good relationship with each other and the people living in the home and the inspector witnessed lots of interaction and laughter. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 10 One lady could not praise the staff highly enough when describing the care and support she had received following hospital treatment and surgery and her recuperation at the home. The care plans for 3 people were examined in detail: these provided a very clear, well-written description of each person’s needs and the action required by staff to meet those needs. Each plan had been reviewed monthly and included a summary of the previous month’s events that enabled staff to assess the person’s well-being and any progress or otherwise with their health care. Staff were found to be very knowledgeable about the care needs of the people living in the home. The District Nursing Service visits the home regularly to support the staff in meeting health care needs. People with terminally illnesses may remain in the home if the District Nurse and the staff can continue to meet their needs. Funeral wishes and favourite hymns are recorded in the care plans. The home had ceased its practice of secondary dispensing medicines and now uses a measured dose system prepared by the local pharmacist: this reduces the risks associated with putting medicine into a pot to be given at a later time. The staff explained that they were still to become fully familiar with the system but it was found that overall practices were safe. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 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. 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. Social activities provide stimulation and interest and are arranged in response to the wishes of those living in the home. Meals are nutritious, plentiful and varied. EVIDENCE: People said they enjoyed the Prayer Meeting each morning that was lead by a member of a local church. The majority of the people living in the home attended these meetings and enjoyed morning coffee together afterwards. The Registered Manager described that people were encouraged to maintain their own interests and to use the local community facilities but that the number and frequency of leisure activities had reduced recently in response to the wishes of those living in the home, the average age of whom is 95years. The home has a minibus to enable trips to local places of interest. People confirmed that their family and friends are made very welcome and they can visit at any time. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 12 The food was described as plentiful and “very good” and “excellent”, and drinks and snacks were available at all times: fresh fruit was available in the dining room. The main meal of the day was at lunchtime however the evening meal consisted of a 3-course meal including the choice of a hot meal. The vegetables and sauces or gravy accompanying the meal were presented in serving dishes and people appreciated being able to help themselves to as much or as little as they wished. Two people who live in the annex share a kitchen and are able to prepare drinks and light meals if they wish. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and suggestions from the people living in the home, their relatives or other visitors are treated seriously and resolved promptly. People’s rights are respected and protected. EVIDENCE: People said that the Registered Manager and the staff were very approachable and they were confident that any issues of concern would be listened to and dealt with. Neither the Commission nor the home had received any complaints since the last inspection. Comment cards are available in the main entrance allowing anonymous comment about the services provided. Many “thank you” cards from relatives had been received expressing their appreciation and praising the quality of care provided at the home. Staff have received training in issues relating to abuse and the protection of vulnerable adults ensuring they are aware of their responsibilities should they suspect someone is at risk of being, or who has been, abused. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Bethany Christian Home is a very pleasant, well-maintained home that is comfortable and which has sufficient facilities to meet the needs of those currently living there. EVIDENCE: The home is in an excellent state of repair; it provides very comfortable communal and private accommodation. Many rooms have beautiful views over Plymouth Sound and the local park. The annex provides more independent living and 2 people share a kitchen in which they are able to prepare drinks and light meals. The majority of bedrooms provide en suite facilities: four bedrooms have recently been upgraded to en suite. Two bedrooms have been lost to provide the additional space needed for these upgrades as well as the creation of a shower room that provides ample space for people to be assisted in comfort. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 15 The other bathrooms are also suitable for use by people with restricted mobility. These recent alterations to the home demonstrate the Trust’s commitment to improving the facilities particularly as this has resulted in a temporary reduction in revenue. An extension is planned to provide 6 additional en suite bedrooms in the area from the annex into the current car park. An additional car parking area has been created in readiness for this. The garden is well maintained and accessible with a patio providing a very pleasant seating area. All radiators were covered and hot water temperatures controlled to prevent the risk of burns and scalds. Approved hold open devices have been fitted to all bedroom doors to allow people to keep their doors open if they wish, while ensuring that the fire protection system remains effective. A hallway has been created next to the laundry room which means that those people living in the annex, and the extension once completed, will not have to walk through the laundry room to access the main house. This reduces the risk of people coming into contact with soiled laundry. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 good. This judgement has been made using available evidence including a visit to this service. Staff are well-trained and motivated, and employed in sufficient numbers to meet the needs of those currently living in the home. Recruitment practices are robust and protect vulnerable people. EVIDENCE: The staff were described by people living in the home as very kind and caring. They confirmed they were assisted promptly indicating there are sufficient staff on duty to meet their needs. Three care staff are on duty during the day and 2 waking staff are on duty during the night. These numbers do not include the Registered Manager or those people who assist her with the management of the home. Care staff are supported by catering and domestic each day. The inspector spoke to the staff on duty and each confirmed that they feel well supported to undertake their role and can seek advise from the Registered Manager at any time. A training programme detailed the ongoing training undertaken by staff ensuring that they have the knowledge and skills to care for older people and to respond to emergencies. Staff confirmed they have attended training in first aid, fire safety and manual handling as well as caring for older people who may be confused or have dementia. Over 50 of staff had completed NVQ training in Care, a nationally recognised qualification for which they have to demonstrate their skills in supporting older people. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 17 A sample of staff files were examined, including those for 2 newly appointed staff. The files held the necessary pre-employment documentation, including 2 written references and a Criminal Record Bureau check, ensuing as far as possible only suitable staff are employed. These 2 new staff have been provided with induction training that provided them with information about the values and principles of good care practices and their responsibilities. One of the staff members was on duty at the time of the inspection and she confirmed that she was working alongside an experienced member of staff until she became more familiar with the needs of the people living in the home. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bethany Christian Home is well managed home. The Registered Manager and her staff team strive to provide a stimulating, safe environment that respects and protects peoples’ rights. EVIDENCE: Since the previous inspection, Mrs Laidler has successfully registered with the Commission as the Manager and has taken over the day-to-day running of the home. Miss Laidler was described as having an “open-door” policy and throughout the inspection, the inspector witnessed her meeting with people on several occasions. People said they feel safe, secure and happy in their home and that the home was well managed. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 19 Relatives are invited to join “Friends of Bethany Christian Home” and have the opportunity to meet with the Registered Manager and a member of the Board of Trustees 3 times a year. These meeting review the management and development of the home and the quality of services provided. A member of the Board of Trustees visits the home unannounced each month to meet with people and staff and to review the standards of care and the environment, ensuring standards remain high. The Registered Manager confirmed that she meets with people on a daily basis to ensure they are satisfied with the care and support they receive. Annual questionnaires are sent to the people living in the home as well as their relatives to ascertain their views about the services provided. The results of the consultation in November 2006 were displayed on the notice board and indicated a high level of satisfaction. Where a suggestion had been made about the menu the action taken by the Registered Manager to address this was included. The fire logbook indicated that the required weekly and monthly testing of the fire alarm system was being undertaken and service contracts ensure equipment is maintained in good working order. The same applies to the servicing of the passenger lift and kitchen equipment. The kitchen and food storage areas were found to be clean and tidy and records of fridge and freezer temperatures were recorded daily indicating that regular cleaning and monitoring were being undertaken. People are encouraged to maintain responsibility for their own finances if they are able to do so and are provided with lockable storage space for money and other valuables. The home does provide safe storage should anyone wish to use this facility. All transactions are recorded for each person and receipts obtained for their records: a sample of these were checked and found to be accurate. Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 4 4 X 4 4 3 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 4 3 X 3 3 3 3 Bethany Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 21 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 Christian Home DS0000003471.V336014.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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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