Random inspection report
Care homes for older people
Name: Address: Bethany Francis House Bethany Francis House 106 Cambridge Street St Neots Cambridgeshire PE19 1PL one star adequate service 26/01/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Derek Brown Date: 1 4 1 0 2 0 0 9 Information about the care home
Name of care home: Address: Bethany Francis House Bethany Francis House 106 Cambridge Street St Neots Cambridgeshire PE19 1PL 01480476868 01480473799 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) ADR Care Homes Ltd Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 34 Number of places (if applicable): Under 65 Over 65 0 34 dementia old age, not falling within any other category Conditions of registration: 34 0 The maximum number of service users who can be accommodated is 34 The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Date of last inspection 1 1 0 8 2 0 0 9 Care Homes for Older People Page 2 of 9 Brief description of the care home This home was sold in October 2008 to ADR care homes, who bought it as an ongoing buisness. They own several other homes. They inherited the current manager and care staff and have implemented a number of changes including a major refurbishment of the property. This was the first key inspection to a newly registered service. Bethany Francis House is a listed building, set back from the main St Neots to Cambridge road. It has large extensive gardens. It is a victorian property which has been extended and provides spacious accommodation on two floors. The upper floor is accessed by a wide sweeping stair case at each end of the house. There is a lift available. The home can accommodate up to 34 people who fall into the category of older people, with or without dementia. There are three double rooms and 28 single rooms. 21 have en suite facilities. The first floor has two bathrooms with hoists and toilets and two individual toilets and one shower room. There are attractive gardens and a number of the residents help with the garden. They have hanging baskets and raised flower beds. The grounds are enclosed and their are suitable seating areas. The home is situated just a few minutes walk from the market town of St Neots where a range of shops and leisure facilties can be accessed. It is close to public transport; the railway station and bus routes. A copy of the homes statement of purpose and service user guide are made available by the home. The current inspection report is available in the hallway. The current fees for the service are 358.00 to 550.00 a week. There are additional charges for items of personal items. Care Homes for Older People Page 3 of 9 What we found:
The reason for this inspection was to assess progress towards meeting the requirements made on the inspection on 11th August 2009. We looked at the practices and procedures for the safe handling, use and recording of medicines. Medicines are stored securely for the protection of residents. The temperatures of the medicines storage rooms are monitored and recorded regularly to ensure the quality of medicines in use. A new cupboard has been installed for the storage of controlled drugs and this meets the legal requirements. The requirement made on the last inspection that medicines must be stored under suitable environmental conditions and controlled drugs must be stored in accordance with legal requirements has been met. We looked at the medication and medication records for several people living in the home. In general these were in good order, account for medicines in use and demonstrate that people receive the medicines prescribed for them. On the last inspection we made a requirement that there must be accurate records of all medicines administered and that the reasons for any omissions must be recorded. We consider this requirement to have been met but we noted that two people whose medicines are given at different times to those printed on the medication administration record chart, the actual time the medication was given was not recorded. We also made a requirement to ensure that supplies of medication do not run out and that there are sufficient supplies for the continued treatment of residents. With one exception, where a medicine was not available for one person for a short period of time, we consider this requirement has been met. We made a recommendation to update the policy and procedures for the safe handling of medicines to be updated to reflect current practice in the home. We looked at the policy documents and saw that these had been updated but some aspects of the policy still did not reflect that the home does not employ nursing staff. We have not rolled forward this recommendation in this report but expect this to be managed by the home. We looked at the care plan for one person who was prescribed medical oxygen and could not find any confirmation of the flow rate the equipment should be set at or how frequent it should be used. Although this confirmation was received during the inspection. We also saw that a risk assessment had been documented for the use of oxygen in the persons room but this must be expanded to include all identified risks. What the care home does well: What they could do better:
Where people are given medication at different times to those printed on the medication administration record then the actual time it is given must be recorded to prevent people receiving medicines too close together.
Care Homes for Older People Page 4 of 9 Where people are prescribed medical oxygen, the risk assessment must be expanded to include all identified risks. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 9 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 27 18 The home must ensure that 30/10/2009 their staff are suitably qualified, competent and experienced. The home must have a clear audit trail of staffs training and induction received. Training records in themselves are insufficient. The home must evaluate the effectiveness of the training provided. This is to ensure that staff have the neccessary skills to meet the requirements of the job. 2 29 19 Staff must have a 30/10/2009 satisfactory protection of vunerable adults, (POVA) check before they are employed. Criminal records checks must be applied for at the earliest opportunity. This is to ensure residents are protected from potentially unsuitable staff. 3 37 17 The staffing rotas must comply with schedule 4, which states that the duty rota must include the position staff hold, the work they perform and the number of hours they work. 30/10/2009 Care Homes for Older People Page 6 of 9 Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action This is to ensure that there is a clear audit trail and the home are able to clearly evidence that care hours are sufficiently covered. 4 38 23 The home must be free from 30/11/2009 hazards. Unguarded radiators must be covered and hot water temperatures regulated so they do not exceed 43 degrees. This was a previous requirement but the home have taken steps to minimise the hazards but have not eliminated them. This is to ensure residents are fully protected. Care Homes for Older People Page 7 of 9 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 8 of 9 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 9 of 9 - 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!
