Inspection on 24/07/07 for Bethany Homestead

This inspection was carried out on 24th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bethany Homestead 29/06/06

Bethany Homestead 26/01/06

Bethany Homestead 04/04/05

Bethany Homestead 25/01/05

Bethany Homestead 28/09/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Bethany Homestead Kingsley Road Northampton Northants NN2 7BP Lead Inspector Judith Roan Unannounced Inspection 24th July 2007 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 Homestead DS0000012601.V341466.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 Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethany Homestead Address Kingsley Road Northampton Northants NN2 7BP 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) 01604 713171 01604 716315 The Trustees of Bethany Homestead Mrs Kathleen Margaret Coxhill Care Home 40 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40) of places Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 The maximum number of service users who can be accommodated is 40 29th June 2006 2. Date of last inspection Brief Description of the Service: The home is situated in a purpose built facility close to the town centre and local amenities. Refurbished in recent years the building has been brought up to modern standards. The home is run by a board of trustees and admits service users who are members of non-conformist churches in the town. Residents are accommodated over three floors with lift access for those with mobility problems. There is a mixture of single and double rooms, all of which have en-suite facilities. The home is set within a complex of sheltered housing and a community centre to which service users have access. The current fees range from £440.00 to £470.00 with additional costs for extras such as hairdressing, newspapers, transport, chiropody and testing of portable electrical appliances belonging to service users. Information about the service can be found within the Statement of Purpose and service users guides available to residents, families and purchasers. Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Service Users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 3 service users and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The inspection took place during the late morning and afternoon, over a period of 6 hours and was carried out on an unannounced basis. The annual quality assurance assessment (AQAA) completed by the Registered Manager and comment cards from residents and their families were also used as evidence for this report. What the service does well: What has improved since the last inspection? Some work has begun on improving the care plans and supporting risk assessments. One hoist has been replaced. Carers are now receiving regular supervisions. Record keeping has improved. Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Bethany Homestead DS0000012601.V341466.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 Homestead DS0000012601.V341466.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good information and assessment practices ensure that resident’s needs are met. EVIDENCE: Good information is available to prospective residents prior to making a decision on moving into the home. In discussion with residents they confirmed that information had been available to them or their relative. A member of the management team at the home undertakes a full assessment of need to confirm that these can be met. Evidence was found within files that assessments had been carried out on a new resident prior to admission. Bethany Homestead DS0000012601.V341466.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans do not provide sufficient detail to ensure that resident’s needs are met. EVIDENCE: Care provided at the home is of a high standard and carers spoken with were aware of the needs of the resident’s case tracked during this inspection. Of the resident’s case tracked the inspector found that all had care plans that had been developed with individuals. It was evident that care plans were reviewed on a regular basis. Plans however do need to contain more detail to inform carers how the identified needs are met. The supporting risk assessments need to demonstrate how risks are minimised by action to be taken by staff. Risk assessments also need to be developed for the range of activities undertaken with and by residents to ensure that potential risks are identified. E.g. trips out, social activities. Medication administration was good and records well maintained. Carers who undertook this responsibility were well trained and competent. Healthcare Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 10 needs are met and there is a good working relationship with visiting healthcare professionals. In observation of care practices throughout the inspection residents treated with dignity and choices respected. Bethany Homestead DS0000012601.V341466.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to access a range of social activities in and outside of the home of their choice. EVIDENCE: Residents spoken with confirmed that there are many activities throughout the week at the home. On the day of the inspection a fund raising coffee morning was taking place where residents in the surrounding homes are invited to socialise. One resident who helps with the arrangements of the event told the inspector that these take place on a regular basis. One resident however commented that there are fewer options for people who have disabilities and have restricted access. Residents who choose to are supported to go to church on weekly basis or had visits from local ministers. Religious festivals were a focal point of several activities within the home. Good information of what was happening at the home was clearly displayed on the notice board in the entrance hall. It was evident that families were welcome as were visitors who were seen to enjoy the social at the home that day. In discussion with several of the residents and their visitors they confirmed that there was always an event happening that individuals could choose to attend, Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 12 The midday meal offered a range of options that residents signed up for the day before. The menu catered for special diets i.e. diabetic, calorie controlled or soft diet and the inspector observed that there was adequate support for residents during the meal. Some residents commented that they were not totally happy with the choice or that the vegetables were not to their liking but generally most were. In discussion with the cook it was evident that she undertook regular surveys by meeting with all of the residents on a 1-1 basis at which time they had said there were no concerns. The food on the day of the inspection was cooked well, presented attractively and showed a healthy balance. Fresh vegetables are always used and fruit is available. The dining room that is spacious provides a comfortable and conducive environment for meals. Bethany Homestead DS0000012601.V341466.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by care practices within the home. EVIDENCE: The complaints procedure is contained within the service users guide and those residents spoken with were fully aware of whom to take their concerns to. Comments made within the surveys also confirmed this fact and all said that they knew how to make a complaint. No complaints had been made since the last inspection. Carers working at the home undertake protection of vulnerable adults training as part of their induction and the Registered manager is aware of the local reporting procedures. Residents felt safe living at the home and consider that the service promotes their rights. Bethany Homestead DS0000012601.V341466.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): 19,22,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good facilities that are well maintained, clean and safe. EVIDENCE: In touring the home meeting with residents it was evident that the team of housekeepers maintain a high standard. The home is clean and in observation good infection controls measures are in place. A recommendation made at the last inspection to replace two hoists has been complied with. The homes environment enables residents that use mobility aids to have access to all parts of the home and its grounds. The home has two assisted bath hoist that enable residents to be supported with dignity. Resident’s rooms seen were personalised with many bringing small items from their previous homes. The room provided a comfortable room where residents could spend their time. Around the home there are several communal area Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 15 that are used for activities. The home has a designated room for services and prayer that is used weekly. The home is surrounded by well maintained gardens that offer outside seating for residents. Bethany Homestead DS0000012601.V341466.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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A well trained and competent staff team support residents at the home. EVIDENCE: Residents spoken with and in surveys all confirmed that the staff team were caring and competent in providing the service at the home. In observation it was evident that there were sufficient numbers of staff to meet the needs of residents. Staff files seen contained all of the information required and it was clear that robust checks were undertaken to protect residents. Staff training has improved and all carers have undertaken manual handling training, as they are legally required to do. The home now has over 50 of the staff trained to at least NVQ (National Vocational Qualifications) level two in care. Two senior carers have achieved NVQ at level four in the past year. New carers receive induction training within their first six weeks of employment that includes fire & health safety, protection of vulnerable adults and care procedures/ practice at the home. Staff spoken with felt well supported by the management team. The homes manager has reflected within the AQAA by stating that improvements could be made in staff meetings, which would enable the team to have a better overview of the home and development. Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 17 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A proactive management and staff team maintains resident’s best interests. EVIDENCE: An experienced manager who ensues that the service is run in the interest of the residents manages the home. The manager’s approach is positive with them demonstrating that they have good rapport with residents and staff. Since the last inspection staff have begun to receive on the job supervision and time to consider work practice and development. Record keeping has improved and the inspector was able to view health & safety records to confirm that regular checks had taken place. The catering manager maintains good records in their area of work. Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 18 Regular feedback from residents and their families is sought to ensure that standards are maintained. In discussion with the manager it would be useful to use the feedback within an annual quality assurance report that could be used as part of the AQAA documentation, information available to prospective residents and management Service users monies are safeguarded by a system of personal accounts. Residents can choose to use this service if they need to. Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 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 Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement Care plans and risk assessments must be detailed and be clear on how care staff members are to carry out care tasks so that residents experience safe and consistent care practices. This requirement was part of a previous requirement made at the last two inspections with an original date for compliance by 30.04.06. Timescale for action 30/10/07 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 Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. Extracts may not be used or reproduced without the express permission of CSCI Bethany Homestead DS0000012601.V341466.R01.S.doc Version 5.2 Page 22 - 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. 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