Inspection on 20/06/06 for Bethany House

This inspection was carried out on 20th June 2006.

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 House 09/02/10

Bethany House 18/09/07

Bethany House 08/12/05

Bethany House 07/06/05

Bethany House 03/03/05

Bethany House 04/10/04

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

CARE HOMES FOR OLDER PEOPLE Bethany House 20 Front Corkickle Whitehaven Cumbria CA28 8AA Lead Inspector Colette Hibbert Unannounced Inspection 20th June 2006 08:45 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 DS0000052971.V291302.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 House DS0000052971.V291302.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethany House Address 20 Front Corkickle Whitehaven Cumbria CA28 8AA 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) 01946 695556 Bethany House Limited Miss Kathryn Lisa Taylor Care Home 17 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2) Bethany House DS0000052971.V291302.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 17 service users to include: up to 15 service users in the category of DE(E) (Dementia over 65 years of age) up to 2 service users in the category of MD/E ( Mental disorder excluding learning disability or dementia over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 8th December 2005 2. Date of last inspection Brief Description of the Service: Bethany House is owned by Mr and Mrs Ditchburn and is part of Bethany House Limited. Mrs J. Ditchburn is the Responsible Individual and Ms Kathryn Taylor is the Registered Manager for the home. Bethany House is situated on the outskirts of Whitehaven close to local amenities. The local bus company runs a service past the home. On street parking provides a limited number of spaces for visitors. The home was a vicarage that had been converted. Accommodation can be provided for up to seventeen older people who require assistance with personal care. The home is not registered to provide nursing care and is staffed accordingly. At present the fees for this home are £422 per week but are under review. Bethany House DS0000052971.V291302.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home took place on 20/06/06 commencing at 08:45 and finishing at 15:00. Before the site visit information had been gathered about the service from the provider. Information on the service provided was gathered from residents and their families using questionnaires before the visit. The morning was spent looking around the home talking with residents in the lounge and in their own bedroom, speaking with the staff and visitors to the home. Activities were also observed and care plans were looked at. Policies and procedures, systems for recording complaints and personnel and training records were looked at in the afternoon as well as other records required by regulation. What the service does well: What has improved since the last inspection? The storage facilities within the home has been improved and residents have easy access to all communal and private areas. The downstairs corridor has been decorated making it much lighter and brighter. The grounds around the home have been tidied and planted to provide a nice area for the residents to sit. Two gates have been fitted to the side of the Bethany House DS0000052971.V291302.R01.S.doc Version 5.2 Page 6 building to improve the safety of the residents. The new security alarm system is now fully installed and working and provides safety for the residents. The staff have improved the storage of cleaning fluid and are now following home procedures and they are stored safely. 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 DS0000052971.V291302.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 House DS0000052971.V291302.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments of health care needs are being done before admission to ensure the residents individual needs can be met. Each resident has a written contract stating terms and conditions of the home EVIDENCE: Prospective residents are given information about the home before they are admitted. The home has a statement of purpose and a service user guide and residents spoken with said that they had been given copies prior to admission. Either the manager or registered provider assesses the residents before they are admitted to ensure that the home can provide for their social and care needs. One resident spoken with said that they had visited the home several times before moving in. Each resident is given a written terms and conditions and the home retains a copy of this. Bethany House DS0000052971.V291302.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has a care plan in place but it does not always contain up to date and current information to identify the residents care needs. Medication records must contain all appropriate information for monitoring and safeguarding residents. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Each resident has a care plan containing pre admission assessments and has comprehensive information relating to the social and care needs of the residents. Some of the information had not been updated to indicate the residents’ changes in care needs. Medication administration was observed and found to comply with the homes policy on administration. The medication charts were signed and notes made if medication had been omitted. There was no documentation of the residents on Digoxin having their pulse taken prior to taking the medication. A member of staff said that they did do this as routine but did not document it, and would start to do this in future. Bethany House DS0000052971.V291302.R01.S.doc Version 5.2 Page 10 Staff were observed throughout the day with the residents. It was obvious that they had a good relationship with the residents and difficult situation were defused in a calm compassionate manner. Residents spoken with said that they felt that all their needs were met by the staff. Bethany House DS0000052971.V291302.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A variety of activities are delivered to suit the needs of the residents within the home. Residents are given the opportunity to make choices and contact with family and the wider community is encouraged. The home offers a varied menu and choice of food and catered for special dietary needs. EVIDENCE: The evening before the inspection six of the residents and two staff members had attended a local tea dance. This had obviously been enjoyed and the residents went into great detail to tell the inspector all about it. Staff said that they also often go out into the town in the mini bus which the residents confirmed. Once a month the mini bus is used to take those who wish to the local church service, and they have visits from clergy of all denominations. Residents are able to make choices as to when they get up and go to bed, were they sit either in the communal area or in their own rooms. Visitors are made welcome and they can call at the home at any time. Staff were observed reading the local paper to a group of residents in the morning and they had a music session in the afternoon for those residents who wanted to join in. Bethany House DS0000052971.V291302.R01.S.doc Version 5.2 Page 12 Lunch was served in a very relaxed atmosphere and residents were discreetly assisted as required. The residents were offered a choice of food and it was served in appropriate portions. One resident spoken with said that ‘the meals were very good, the cook knows what we all like’ Bethany House DS0000052971.V291302.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a clear complaints procedure in place and the residents were aware how to make a complaint. Adult protection procedures were in place and training provided on this to staff to promote residents’ safety and well being. EVIDENCE: The home has a clear complaints procedure in place, residents spoken with said that if they had a complaint that they would go and see the home manager and she would ‘sort it out’. One relative said that she felt the home would take any concerns seriously and act upon them in an appropriate manner. Adult protection procedures are in place and guidance has been given to the staff. This was confirmed by the staff who were aware of what action they would take to protect the residents in their care. Bethany House DS0000052971.V291302.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24,and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained and all areas are decorated and furnished to a satisfactory standard to provide a comfortable, clean and homely environment for the people who live there. Aids and adaptations are provided to promote the resident’s independence EVIDENCE: The home is in general well maintained but the staff need to be aware of the system in place for reporting any minor maintenance that is required. The communal areas were all well decorated, light and homely and the residents had the choice of two seating areas. The dinning area provides ample space for all the residents to sit and enjoy their meals if they wish. Residents rooms had been personalised some residents have pieces of their own furniture in their rooms making them individualised. The corridor areas Bethany House DS0000052971.V291302.R01.S.doc Version 5.2 Page 15 have hand rails to promote independence and there is a stair lift to the upper floor. The home was very clean and tidy and has a cleaner on duty every day. The laundry area had been re organised since the last inspection and was much tidier; this was a requirement and has been met. Bethany House DS0000052971.V291302.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff on the duty rota are adequate to meet resident’s care and social needs Procedure for the recruitment of staff offers protection to the people living in the home. Staff training and supervision being given helps to consolidate and improve the service provided to the residents. EVIDENCE: There was sufficient staff on duty during the day of the inspection to meet the residents care needs. Care staff and the cleaning staff cover the laundry duties and staff felt that they were able to do this. The home carries out the required pre employment checks to secure the safety of the residents within the home. Residents spoken with said they did not have to wait for attention and call bells were answered promptly. Staff training continues on a rolling programme with staff undertaking NVQ II and III Staff records showed that training had been given in Moving and Handling, Fire Safety, and full inductions were given on commencement of employment. Bethany House DS0000052971.V291302.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has an understanding of the areas in which the home needs to improve to provide a consistent and safe environment for the residents. The home works closely with residents and families to affect the way the home is run. Policies and procedures are in place to safeguard residents’ welfare and finances EVIDENCE: The manager has done reviews on policies and procedures and staff, residents and relatives are involved in improving working systems in the home. Policies and procedures are in place to protect the residents’ finances. Only small amounts of money are kept on the residents’ behalf and this is checked for accuracy by the manager and the provider. Bethany House DS0000052971.V291302.R01.S.doc Version 5.2 Page 18 Although the home has some records of servicing its equipment there was no evidence that all equipment required to be serviced under the regulations was being carried out. This must be improved to ensure the residents’ safety. There has been an improvement in the storage of cleaning fluid and it is now stored away within a locked cupboard. This was a requirement made at the last inspection and has been met. Bethany House DS0000052971.V291302.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 3 3 3 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 2 3 X 2 3 2 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 2 2 Bethany House DS0000052971.V291302.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 2 3 4 5 6 Standard OP7 OP9 Regulation 15 13 23 16 14 26 Requirement Care plans must be accurate and up to date Staff must monitor and record the pulse of residents taking Digoxin medication. The home must introduce a better system for reporting maintenance problems Old and broken equipment must be replaced. The windows within the residents bedrooms should be able to open to allow for ventilation if required The responsible individual must send a monthly report to CSCI on the operations of the home This is an outstanding requirement with a timescale from 28/02/04 The home must service and maintain the equipment and keep current service certificates and documentation. Timescale for action 30/10/06 30/10/06 30/10/06 30/10/06 30/10/06 30/10/06 OP19 OP22 OP24 OP37 7 OP38 13 30/10/06 Bethany House DS0000052971.V291302.R01.S.doc Version 5.2 Page 21 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 House DS0000052971.V291302.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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. 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