Inspection on 15/12/05 for Bethany House

This inspection was carried out on 15th December 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 16/12/08

Bethany House 09/01/07

Bethany House 12/04/05

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Bethany House 3 Margaret Road Harrogate North Yorkshire HG2 0JZ Lead Inspector Mrs Maggie Coxon Unannounced Inspection 15th December 2005 11:30 Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 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 DS0000063607.V269833.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 Adults 18-65. 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 DS0000063607.V269833.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bethany House Address 3 Margaret Road Harrogate North Yorkshire HG2 0JZ 01423 501650 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) Franklin Homes Limited Mrs Maria Oakes Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th April 2005 Brief Description of the Service: Bethany House provides personal care and accommodation for up to 8 adults who have mental health problems. The home is situated in a pleasant residential area of Harrogate and is within easy reach of the town centre its amenities and facilities. The people who live there have single bedrooms most of which are en suite. There is a variety of communal space available for their use. The accommodation is over four floors and accessed by flights of stairs. There is parking available on the road at the front of the house. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection to be undertaken between April 2005 and March 2006. It was done on 15th December 2005, at a time when all of the people living in the home would be present. It took 4 hours plus 1 hour’s preparation time. Discussions were held with all of the seven people currently living in the home, with care staff on duty, with the registered manager and with the general manager of the organization who also attended. A number of records and most areas of the home, including bedrooms and shared areas, were seen. What the service does well: There is a very relaxed and happy atmosphere in the home and the staff team communicates very well with individuals who are encouraged to make as many choices and decisions as possible. The team is committed to putting the needs and wishes of the residents first and individuals are encouraged to be as independent as possible although there is always someone on duty at any given time to ensure that residents are given individual attention where required. They are involved in the day-today running of the home as much as possible and are supported, as necessary, to get out and about in their local community and beyond. Care planning systems are in place, which help management and staff to decide if and how they can meet the health and social care needs of prospective residents. These systems also help staff to understand and meet the needs and wishes of people currently living in the home including any changes to these. The home is well maintained and was clean, warm and comfortable at the time of this inspection. All of the residents said that they like their own bedrooms and each has chosen the décor and has included his or her own belongings. Good systems are in operation, which are supported by well-maintained records. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 6 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 House DS0000063607.V269833.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 and 5. Residents are able to make an informed choice about moving in and can be confident that their needs are understood and will be met. EVIDENCE: The registered manager explained that she receives an assessment of potential residents from their care manager prior to the individual’s admission. Once admitted the staff team undertake a further assessment with input from the individual concerned. A care plan is then developed. A well-structured introductory programme for prospective residents is followed and the person concerned is invited to visit the home and meet the other residents and the staff team. Overnight stays are then offered prior to a decision about the placement being made by all concerned. The views of the other residents are listened to and considered before any placement is offered. Residents’ contracts have been amended and now give a breakdown of the fees and who is responsible for paying them so that individuals might have a better understanding of the financial arrangements. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. People living in the home make as many decisions about their personal lives and about the day-to-day running of the home as possible. They also live as independently as possible, taking into account any risks that have to be considered, with the full encouragement and support of staff. EVIDENCE: A care plan has been developed for each resident that outlines the individual’s skills and needs and identifies how these needs are to be met. These care plans are regularly reviewed with input from the resident concerned. All of the residents lead interesting and active lives with the support of a committed staff team. They are involved in the running of the home as much as possible and have regular meetings where they can discuss any aspects of living in the home. Residents have independent lifestyles and can take calculated risks subject to the outcome of a risk assessment undertaken by the staff team. No restraints are placed on any of the residents. These risk assessments are well detailed but although the registered manager explained that these are reviewed on an ongoing basis, there is no record to show that this is being done. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Residents have a varied and interesting lifestyle and are fully involved in their local community. Individuals enjoy a range of employment, educational and social opportunities enabling them to have a number of different life experiences. They also develop and maintain good relationships with family and friends. EVIDENCE: Residents lead interesting and active lives with the support of a committed staff team. Several of them have a regular programme of activities in a variety of local community based settings including paid and voluntary employment and college courses. They have very busy social lives within their local community. Residents are supported to develop and maintain relationships with families and friends. Residents said that they are fully consulted about menus and are involved in their planning. They said that the meals provided are good. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20. Residents’ personal and health care needs are fully met. EVIDENCE: Each person living in the home is registered with a GP through whom specialist health services are accessed if required. Staff support them in receiving services from primary health care teams, secondary psychiatric services as well as from their dentist, chiropodist and optician. The registered manager and staff team are very forward thinking and are committed to putting the needs of the residents first at all times. They were seen to communicate very well with individuals and to support them in a way that respected their dignity. None of the residents is able to take their own medication. Most of the medication is dispensed via a monitored dosage system; the remainder is bottled or boxed. All medication is securely stored. The system has been improved so that decanting of medication when people go home for a visit or out to day care no longer happens. Medication administration records are well maintained. All of the staff team have undertaken appropriate medication training. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents’ concerns are appropriately dealt with and their interests are safeguarded. EVIDENCE: There is a comprehensive complaints procedure in operation that is made available to anyone who wishes to see it. No complaints have been made to the home or to the C.S.C.I. within the last twelve months. Staff have developed very good relationships with the residents and were seen to communicate extremely well with them. Comprehensive adult protection policies are in place and all staff have had adult protection training. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30. The standard of the environment is good and provides residents with a safe, comfortable and clean place in which to live. EVIDENCE: The home is well maintained and pleasantly decorated and furnished throughout. All eight bedrooms are for single accommodation and are of a suitable size. They are all very pleasantly decorated and are furnished to suit the taste and needs of the individual. Six of the bedrooms have en suite facilities and there is a shared bathroom close to each of the other two bedrooms. The registered manager explained that plans to have an independent shower unit installed are in hand. Other shared areas consist of a kitchen/dining room and a lounge. There is a rolling programme of redecoration in progress and several communal areas have also recently been redecorated including the lounge. A good standard of cleanliness is maintained throughout. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35 and 36. The residents receive a good standard of care from a highly skilled, experienced and motivated staff team. EVIDENCE: The staffing roster for the week including the inspection shows that staff are employed in sufficient numbers and are deployed in such a way as to ensure that the needs of people living in the home are met at all times. During the day there are either 2,3 or 4 staff on duty and during the evening either 2 or 3. Two care staff sleep on the premises every night. Whilst none of the care staff has yet completed their award, two of the seven are currently undertaking an NVQ to level 2 and a further three are undertaking an NVQ to level 3. All staff have also received recent training on mental health issues, on adult protection and training on autism awareness is being planned. All staff receive formal supervision from the registered manager on a monthly basis. Records of this supervision are maintained. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 38. The residents benefit from a well managed home in which their needs and wishes are put first. EVIDENCE: The registered manager has several years’ management experience and is in the process of completing the Registered Managers Award as part of an appropriate qualification. She explained that she has links with several mental health professionals in the area and it was recommended that she contact these to ask if she might spend time with them in their work to consolidate her knowledge and broaden her experience of services for people with mental health needs. Care Staff said that the registered manager is extremely approachable, friendly and supportive. She invests a great deal into developing and maintaining a strong and happy staff team. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bethany House Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 3 X X X X X DS0000063607.V269833.R01.S.doc Version 5.0 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. 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. 2. 3. Refer to Standard YA9 YA32 YA37 Good Practice Recommendations Reviews of risk assessments should be recorded on the risk assessment form. A minimum of 50 of care staff should be qualified to NVQ level 2 or above. The registered manager should complete an appropriate management qualification. The registered manager should take up any opportunities available to her to broaden her experience and knowledge of services within the community for people with mental health problems. Bethany House DS0000063607.V269833.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000063607.V269833.R01.S.doc Version 5.0 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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