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Inspection on 24/02/10 for Bethany Francis House

Also see our care home review for Bethany Francis House for more information

This inspection was carried out on 24th February 2010.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Medicines are stored securely for the protection of residents.

What the care home could do better:

Where people are prescribed medicines on a `when required` basis, there must be clear guidance in care plans of the circumstances they are used and staff must follow thisguidance. Medication must be given in accordance with the prescriber`s instructions. Records made when medicines are given to people must be accurate and complete.

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 09/12/2009 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: 2 4 0 2 2 0 1 0 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 0 9 1 2 2 0 0 9 Care Homes for Older People Page 2 of 11 Brief description of the care home This home was sold in October 2008 to ADR care homes, who bought it as an ongoing business. They own several other homes. 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 ensuite 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 reader should check what the current fees are for the service. At the last key inspection in January 2009 they were 358.00 to 550.00 a week. There are additional charges for personal items. Care Homes for Older People Page 3 of 11 What we found: At the key inspection in December 2009 we made a requirement that where people are prescribed medicines on a when required basis, there must be clear guidance in care plans of the circumstances they are used and staff must follow this guidance. On this inspection, we looked at the care plans for two people prescribed such medication. One of these had detailed guidance on the use of the medication but the other did not. In one case where medication was given, the reason for its use recorded in the daily record of care given, did not follow the guidance in the care plan. This requirement has therefore not been met in full but given the improvement in care planning we have given the requirement a new timescale for action. Future failure to comply with the requirement may result in enforcement action. We also made a requirement that there must be sufficient supplies of medicines held in the home for the continued treatment of residents. We looked at the medication and medication records for several residents of the home and did not find any evidence that medication had been omitted as supplies had run out. We therefore consider this requirement has been met. A requirement was also made that medication must be given in accordance with the prescribers instructions. We found one example where a medicine was prescribed to be taken regularly once a day but the medication administration record showed that it was only given to the person when they needed it. We could find no record in the care plan that this variation to the instructions for the medicine had been discussed with or agreed with the prescriber. This requirement has therefore not been met in full but given that only one example was found it has been given a new timescale for action. Future failure to comply with the requirement may result in enforcement action. We also made a requirement that records made when medicines are given to people must be accurate and complete. We looked at these records for several people living in the home and there have been improvements over previous inspections. However, we found that when peoples medication has been omitted, the reason for the omission was not always being recorded. This requirement has therefore not been met in full but given that improvements have been made it has been given a new timescale for action. Future failure to comply with the requirement may result in enforcement action. At the key inspection in December 2009 we recommended that when hand-written changes or additions are made to the printed medication records that these entries are signed and dated by the person making the entry and checked for accuracy by a second person, who should also sign the record. We found that this recommendation has been implemented. What the care home does well: What they could do better: Where people are prescribed medicines on a when required basis, there must be clear guidance in care plans of the circumstances they are used and staff must follow this Care Homes for Older People Page 4 of 11 guidance. Medication must be given in accordance with the prescribers instructions. Records made when medicines are given to people must be accurate and complete. 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 11 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 7 15 Care plans must reflect 30/12/2009 changes in residents needs and agreed actions to be taken to continue to meet those needs. Particular attention must be paid to the reduction in falls. The home must evidence what actions they have taken and draw up individual risk assessments. This is to ensure that residents have their needs met and they are kept as safe as possible without imposing on their independence. 2 9 13 Records made when 31/03/2010 medicines are given to people must be accurate and complete. This will demonstrate that people receive the medicines prescribed for them. This requirement has not been met in full by the given timescale of 31/12/09 3 9 15 Where people are prescribed 31/03/2010 medicines on a when required basis, there must be clear guidance in care plans of the circumstances Page 6 of 11 Care Homes for Older People 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 they are used and staff must follow this guidance. This will protect people from harm and ensure medication is not given inappropriately. This requirement has not been met in full by the given timescale of 31/12/09 4 9 12 Medicines must be given to people in accordance with the prescribers instructions. This will ensure people receive their medicines as intended by the prescriber. This requirement has not been met in full by the given timescale of 31/12/09 5 12 12 The home must demonstrate 30/01/2010 how residents choices are promoted in relation to all aspects of the home. Routines of daily living must reflect the wishes of residents and not be driven by the staffing culture. This is to ensure the home matches the cultural, social and dietary needs and wishes of residents. 6 26 23 The home must be 30/01/2010 maintained to high standards of cleanliness and adequate arrangements in place to control the spread of infection. 31/03/2010 Care Homes for Older People Page 7 of 11 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 residents are safe. 7 27 18 The home must have sufficient care staff on duty to meet the assessed needs of the residents. The home must employ sufficient numbers of domestic and catering staff. This is to ensure residents care needs are met. And to ensure the home meets the standards relating to food, meals, nutrition and hygiene. 8 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. 9 29 19 Staff must not be employed at the home until all the required information is in place regarding their suitability for employment. This is to ensure people using the service are properly protected. 10/02/2010 10/02/2010 Care Homes for Older People Page 8 of 11 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 10 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. 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. 30/10/2009 11 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 9 of 11 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 10 of 11 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. 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