Inspection on 07/06/05 for Bethany Christian Home

This inspection was carried out on 7th June 2005.

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

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

Other inspections for this house

Bethany Christian Home 05/06/07

Bethany Christian Home 14/12/05

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 PL4 8QE Lead Inspector Jane Gurnell Announced 7 June 2005 th 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 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 D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bethany Christian Home Address 2 Woodside, Lipson, Plymouth, Devon, PL4 8QE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 220692 01752 220692 Bethany Christian Homes Trust Mr Graham Reginald Todd Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service Users Aged 60 Date of last inspection 23/11/2004 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 24 bedrooms, two of which are double rooms. 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. Many of the rooms have views over Plymouth Sound and others overlook a public park. Residents 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 to the residents. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place on 7th June 2005. The focus of the inspection was to consult with residents and staff and to review the care plans and other documentation relating to the management of the home. The inspector spoke to 18 residents, each member of staff on duty including the managers, the deputy manager and the cook, as well as a visitor; toured the building; examined the care plans for a number of the residents spoken to and also the documentation relating to the safe keeping of residents’ money and issues relating to health and safety. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4 and 5 Thorough and comprehensive systems for admission allow service users and their relatives to be confident that their needs can be met. EVIDENCE: Pre-admission assessments are undertaken for all prospective residents and the assessment for a newly admitted resident was available. Care Managers’ and hospital discharge assessments were also obtained prior to admission. This ensured that the care staff were aware of the residents’ needs prior to their admission. Residents described that they had been able to visit the home prior to making a decision to move in. The majority of residents said that they had been aware of the home prior to admission through visiting friends and church members who were already resident and they had already decided that they wished to move into Bethany when they were in need of residential care. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11 Residents’ health, personal and social care needs are being met and residents are treated with great respect. Secondary dispensing of medication increases risk to residents. EVIDENCE: Residents said that they feel very well cared for and can ask at any time for assistance, a number of residents said that nothing was too much trouble for the staff. Two residents particularly wanted the inspector to know how well they been cared for through recent and ongoing illnesses. Care plans described the residents’ needs in detail and provided a monthly summary. One senior member of staff has undertaken training with the Osteoporosis Society to assess residents at risk from falls and those with poor bone density: this has resulted in a number of residents having their medication reviewed and calcium supplements given. Care of terminally ill residents was discussed and residents would be supported to remain in the home if the staff and District Nursing Service could continue Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 9 to meet their needs. Funeral wishes and favourite hymns are recorded in the residents’ care plans. A daily secondary dispensing administration system is in use: each residents’ medication is dispensed into a labelled container detailing the name of the resident, the medication and the time of administration. Only senior members of staff dispense and administer medication and the members of staff involved in this process are identified on the daily medication administration sheet. This system of medication administration was considered by the inspector to be acceptably safe in the circumstances. However secondary dispensing is not recommended under the guidance produced by the Royal Pharmaceutical Society. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Social activities are managed well and provide interest for the service users. Meals are nutritious and varied. EVIDENCE: A variety of leisure and social activities are planned to provide stimulation and interest for the residents. Residents are encouraged to maintain their own interests and to use the local community facilities. Staff support those residents who need assistance to take a daily walk. Religious services are offered daily. A visitor said that she is always made welcome and found the manager and staff very friendly. Residents said that the food was plentiful and very good and that drinks and snacks were available at all times. Two of the residents who live in the annex share a kitchen and are able to prepare drinks and light meals if they wish. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 Complaints and suggestions from residents, relatives or other visitors to the home are treated seriously. Residents’ rights are respected, they are listened to and issues resolved promptly. EVIDENCE: Residents said that Mr Todd, the Registered Manager, and Mrs Todd, who is responsible for overseeing the care of the residents, were very approachable and they were confident that any issues of concern would be listened to and dealt with. No complaints had been received since the last inspection. Any concerns raised by residents or relatives are recorded in the residents’ care plans. Comment cards are available in the main entrance allowing anonymous comment about the services provided. Staff have received training in issues relating to abuse and the protection of vulnerable adults and further training has been identified for later in the year. All the exit doors from the building are linked to the call bell system to alert staff to residents leaving the building both at night and during the day. This system maintains the safety of the residents who would not be safe to leave the home without support. This system does not limit the freedom of the majority of residents who are able to come and go without restriction. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The residents live in a very pleasant, well-maintained home that is comfortable and warm and which provides sufficient facilities to meet their needs. EVIDENCE: The home is in an excellent state of repair; it provides very comfortable communal and private accommodation many with views over Plymouth Sound and the local park. Toilet and bathing facilities are suitable for the use of residents with restricted mobility. The garden is well maintained and accessible: a new patio was being laid on the day of the inspection providing a very pleasant seating area. All radiators were covered and hot water temperatures controlled to prevent the risk of injury to the residents. Approved hold open devices have been fitted to all bedroom doors to allow residents to keep these doors open if they wish, while ensuring that the fire protection system remains effective. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Residents are cared for by well-trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment practices protect residents. EVIDENCE: Residents described the staff as very kind and caring and confirmed they responded promptly to requests for assistance. Care staff are supported by catering, domestic and maintenance staff and they confirmed that there are sufficient staff to meet the needs of the current residents. A training programme detailed the ongoing training undertaken by staff ensuring that they have the skills to care for older people. Sixty-Five percent of staff had completed NVQ training. Examination of staff files indicated that the necessary documentation was obtained prior to employment. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37 and 38 Residents live in a well managed home. The managers and their staff team strive to provide a stimulating, safe environment that respects and protects residents’ rights. EVIDENCE: Residents said that they feel safe and secure in their home and that the home was well managed. Staff said that Mr and Mrs Todd have an “open-door” policy and they are kept informed of significant events relating to the running of the home and the welfare of the residents. Relatives are invited to join “Friends of Bethany Christian Home” and have the opportunity to meet with the Mr Todd and a member of the Board of Trustees 3 times a year to discuss the management and development of the home and the quality of services provided. A member of the Board of Trustees visits unannounced each month to meet with residents and staff and to review the standards of care and the environment. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 15 The fire logbook indicated that the required weekly and monthly testing of the fire alarm system was being undertaken. Staff had received fire safety training in March and May 2005. There was a service contract for the passenger lift and this had been serviced in April 2005. 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. Money was kept for safe keeping for a number of residents and a sample of these were checked and found to be correct. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION 4 4 4 3 4 4 4 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 4 3 3 3 3 3 3 Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 17 no Are there any outstanding requirements from the last inspection? 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 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. 1. Refer to Standard OP9 Good Practice Recommendations The home should explore options to introduce a system of medication administration that does not involve secondary dispensing, and which is therefore compliant with Royal Pharmaceutical Society Guidance. Bethany Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Christian Home D52-D04 S3471 Bethany V221948 070605 Stage 4.doc Version 1.30 Page 19 - 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. 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