Inspection on 01/11/05 for Bethany House

This inspection was carried out on 1st November 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 House 06/11/07

Bethany House 03/10/06

Bethany House 26/04/05

Bethany House 18/01/05

Bethany House 04/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Bethany House Gamull Lane Ribbleton Preston Lancashire PR2 6TQ Lead Inspector Ms Susan Dale Announced Inspection 1st November 2005 10:00 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 House DS0000009839.V252454.R01.S.doc Version 5.0 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 House DS0000009839.V252454.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bethany House Address Gamull Lane Ribbleton Preston Lancashire PR2 6TQ 01772 792226 01772 792226 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) Preston Bethany Trust Miss Marian Hughes Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 27 service users in the category of old age, not falling in any other category (OP) over 65 years of age The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 26th April 2005 Date of last inspection Brief Description of the Service: Bethany House is a Residential Care Home for the Elderly, built and managed by Preston Bethany Trust, a Christian Charity (Registration No. 511535). The home provides personal care to older persons over the age of sixty-five years and is purpose built and the accommodation for service users is all on the ground floor. The home has recently been extended and now has the benefit of a large 2nd lounge and an easily accessed patio area. The home is situated within its own grounds, close to local shops and other community facilities. Accommodation is available for long term, short term, and respite care for Service Users with physical, medical, spiritual and social needs. Assistance is provided to enable each service user to follow their religious faith within the home and encouragement to participate in a local church of their particular denomination. Terminally ill Service Users needing nursing care or with Alzheimers disease are not accepted for accommodation, but should a Service Users condition deteriorate during their stay, every effort would be made to assist them using outside agencies. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the inspector was able to examine various documents as well as talk to service users, staff and a relative. A tour of the premises took place and there was a good response from comment cards provided prior to the inspection with 20 returned from service users and 12 from relatives or friends. What the service does well: What has improved since the last inspection? The home is constantly looking to improve in all areas and has been extended; this has improved the facilities with a separate dining room and lounge as well as 12 additional bedrooms with en-suite facilities. The home now has three assisted bathing facilities and there are now two sluices plus a sterilizer. A new emergency call system has been installed within the service users bedrooms. One lady is being provided with respite care Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 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. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 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 House DS0000009839.V252454.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 4 Up to date written information about the home is available and each service user is provided with the terms and conditions/contract when they commence. EVIDENCE: The statement of purpose and service user guide that provides information about the services within the home has been reviewed an up-dated. New service users can be sure that the home is suitable for them by the decisions reached at the initial assessment and there ability to sample the services prior to permanent residency. Specialised equipment is available for particular service users including talking newspapers and books for service users with sight problems and special mattresses have been provided for three service users. The home does not provide intermediate care. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 & 11 Service users are treated with respect and their privacy is respected. Policies and procedures are in place for when a service user dies whilst residing at the home. EVIDENCE: Evidence was provided from observation, comment cards and talking to service users and staff that privacy and dignity are respected at all times. Comment cards also indicated that the service users felt well cared for and were treated well by the staff. All staff are informed of the homes expectations in relation to treating service users with respect and dignity at all times and they are not allowed to work alone unless the manager is confident in their ability to work in a professional manner. Service users confirmed that they receive their mail unopened and a public telephone is available for use as well as one within the office to ensure privacy. The home has a policy on death and dying which ensures the situation is dealt with in a dignified manner with as little trauma as possible. Relatives and friends are able to stay with the service user as they wish and the manager ensures every support is offered. As soon as possible or when thought appropriate the service users’ wishes with regard to their death or dying are Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 10 recorded and the person to be notified when the time of death is near is recorded. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 15 Service users are allowed and encouraged to be as independent as possible and are able to choose from a selection of nourishing meals provided within attractive surroundings. EVIDENCE: Evidence was provided from talking to service users and records, that all service users are encouraged to maintain personal autonomy and choice, independent advocates are available to act in the interests of service users as necessary. Service users are able to bring their own personal possessions into their private accommodation according to the space available. Access to personal records is facilitated for service users. Service users confirmed that meals offered variety and choice and that they are provided at regular intervals. There were 20 comment cards returned from service users who all confirmed that they liked the food. Menus are planned on a two weekly rota and cater for any service user on a specialised diet. Mealtimes were seen to be unhurried and assistance provided discreetly. Alterations have been made to the home and there is now a separate large dining room that provides very attractive surroundings. Visitors are made to feel welcome at any time and are able to have a meal with the service users. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 16 & 17 There is an appropriate complaints procedure operating within the home and service users’ legal rights are protected. EVIDENCE: There are appropriate procedures in place for any concerns and complaints to be raised and service users indicated that they knew whom to approach in the event of any concerns. Comment cards from relatives and friends indicated that they were aware of the complaints procedure and had never had to make a complaint. There have been no complaints to the home in the last 12 months or to the Commission for Social Care Inspection. Service users are able to participate in the civil rights process by either a personal visit or a postal vote. According to the registered manager the polling station is located very close to the home and most of the services users are able to make a personal visit assisted by the staff. Leaflets about the advocacy service are available within the home for any service user requiring independent help with their personal circumstances. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 21, 22, 23, 24, 25 & 26 Service users live within comfortable safe surroundings that are well maintained and meet all their needs. EVIDENCE: There are ample washing, toilet and bathing facilities to meet the needs of the service users. Each service user has a toilet in close proximity to their personal accommodation. The new extension has 12 bedrooms with an ensuite toilet and basin. Currently there are 3 assisted bathing facilities, two baths and a shower and 6 communal toilets. Throughout the building there are various aids and equipment that following an assessment have been provided to meet the needs of the service users. Grab rails and assisted toilets and bathing facilities are provided and doorways have sufficient width for wheelchair access. A Stand Aid has been purchased to assist staff and service users with poor mobility. The district nurses have provided special mattresses for individual service users following an assessment of need. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 14 The service users’ private accommodation is furnished and equipped to meet their individual needs. Furniture and fittings are of a high standard and include lockable storage space for any valuables or medication. All rooms are centrally heated this can be regulated by the service user by means of a thermostatic valve. All radiators have been covered in order to provide safe surface temperatures. All hot taps are fitted with safety valves that ensure the safe delivery of hot water; a record is maintained of the water temperatures to confirm the temperature ranges between 40 and 46 degrees centigrade. The home has suitable policies and procedures for the control of infection, including what to do in the event of an outbreak of infection; protective clothing is available and work restrictions for staff and isolation rooms. The laundry is sited to ensure that soiled articles are not carried through areas where food is stored or prepared and has a washing machine that has an appropriate washing temperature. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 There are enough staff on duty to cover the needs of service users and staff have been provided with training that ensures they are competent to do their job. EVIDENCE: Staffing rotas were provided that show there are sufficient numbers of staff on duty at all times and service users and a relative spoken to confirmed that they had no concerns over the staffing levels. There were 12 comment cards returned from the relatives or friends of service users who stated that when they had visited the home there were sufficient numbers of staff on duty. There are currently 22 care staff and 5 staff have obtained an NVQ qualification, there are a further 5 care staff in the process of obtaining an NVQ qualification. As well as Induction Training, evidence was provided that a stafftraining programme is in operation that meets National Training Organisation specifications. Staff had received training in Medication Awareness; Manual Handling; First Aid; Parkinson’s disease; Preventing Falls & Fractures; Continence and Diabetes update. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35, 36, 37 & 38 Staff and service users benefit from the leadership of the manager and policies and procedures are in place that ensures the protection and safety of service users. EVIDENCE: The registered manager has many years experience in care and the management of care and has obtained an N.V.Q. qualification in Care and Management at level 4. Staff and service users spoken to have indicated that there are clear lines of accountability within the home and they have felt safe under the leadership of the current registered manager who is shortly to retire. A new manager is currently being registered with the Commission. Staff meetings are held on a regular basis at which minutes are taken and daily meetings are held to discuss any issues that have arisen. The chairman of the home’s board of trustees visits the home on regular basis and speaks to service users and staff and the information gathered is then fed back to the staff within the home as well as to the Commission for Social Care Inspection. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 17 Policies and procedures are in place with regard to any financial transactions required on behalf of the service users. A written record of all transactions on behalf of service users is maintained. Secure facilities are available for the safekeeping of any valuables or money. There was evidence that staff receive individual supervision at least six times a year. Supervision covers all areas of practice and the philosophy of care within the home. All other staff are supervised as part of the management process. All records seen were up to date and accurate. Access to individual records is available and service users are encouraged to help maintain their own personal record. The manager ensures that the health, safety and welfare of service users and staff are promoted as is reasonably practicable. Staff training is provided in all key areas. The manager and senior staff have attended courses in First Aid. The home has appropriate Health and Safety policies and a qualified contractor services the boilers and electrical systems. Windows are fitted with restrictors and there is an intruder alarm system. Risk assessments are in place in relation to safe working practices throughout the home. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 18 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x X X 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 3 3 3 Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 19 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. 1 Refer to Standard OP28 Good Practice Recommendations NVQ training of care staff should continue. Bethany House DS0000009839.V252454.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 House DS0000009839.V252454.R01.S.doc Version 5.0 Page 21 - 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!