Inspection on 22/11/05 for Bethany House

This inspection was carried out on 22nd 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 06/09/07

Bethany House 22/08/06

Bethany House 07/06/05

Bethany House 21/02/05

Bethany House 03/08/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Bethany House 30 Eastbridge Road Dymchurch Kent TN29 0PG Lead Inspector Lisbeth Scoones Announced Inspection 22nd November 2005 09:30 Bethany House DS0000023355.V257249.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 DS0000023355.V257249.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 DS0000023355.V257249.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bethany House Address 30 Eastbridge Road Dymchurch Kent TN29 0PG 01303 875199 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) Mrs Rosemary Jean Mills Mr Robert Shaun Bowden Mills Mrs Susan Anne Urquhart Care Home 15 Category(ies) of Physical disability (15) registration, with number of places Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents over the age of 65 are restricted to one (1) whose date of birth is 15.12.1936. 7th June 2005 Date of last inspection Brief Description of the Service: Bethany House provides accommodation for 15 younger adults with a Physical Disability who either require nursing or personal care. The home is a purpose built, detached house on two floors, which became operational in 1997. It is close to its sister home Bethany Lodge. The home is located on the outskirts of the small village of Dymchurch, surrounded by attractive gardens and overlooking the countryside. There are car-parking facilities in the forecourt and the home is close to bus services. The home has a hydrotherapy pool and multi-sensory room as well as other services. Residents may use the arts and craft room in Bethany Lodge. The home has a minibus used for trips and outings. All bedrooms are single with en-suite facilities. The home provides a light, spacious, cheerful and bright environment for its rresidents. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 5.5 hours on November 22 2005 and comprised discussions with the director Mr P Mills, manager Mrs S Urquhart, deputy manager Ms S Savage, other staff and two visiting relatives; interaction with all residents; a tour of the building and the examination of records. Prior to the inspection, the director completed a pre-inspection questionnaire and the inspector received 7 comment cards, completed by residents’ relatives. Many positive comments were made. Some relatives felt that at times there were not enough staff on duty. This issue was discussed with the manager and director. What the service does well: What has improved since the last inspection? The care planning format has been reviewed and is now clearer and userfriendlier. The standard for practising universal precautions is good. The deputy manager, following training, has become the home’s infection control link nurse. In-house staff training is to be provided and an audit tool has been developed ensuring a high standard of infection control. Since the previous inspection, outdated exercise regimes on display in residents’ rooms have been removed and this information is now incorporated in the care plans. Bethany House DS0000023355.V257249.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 DS0000023355.V257249.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 DS0000023355.V257249.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): 1, 3 Prospective residents and their relatives have the information they need to make an informed choice about where to live. EVIDENCE: Several relatives commented that they had not read the home’s report. The inspection report was seen on display on the notice board and therefore accessible and available to all who wish to read it. There was evidence that the home arranges access to independent advocacy services for those residents who have no relatives or significant others to speak/act on their behalf. See also standard 7. Bethany House DS0000023355.V257249.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, 9 Staff understand the individual needs of residents as set out in their individual plan of care. Risk assessment tools are adequately used to inform the care plan. Residents are involved in all aspects of life within this home and are enabled, with assistance, to make decisions about their lives. Residents are supported to take risks as part of an independent lifestyle where appropriate. EVIDENCE: Residents have very complex and changing needs and many professionals are involved in providing care. As a result, much information is generated for every resident. Care plans are discussed with residents’ next of kin and key workers contribute on progress made. At the previous inspection, it was recommended that the care planning format be reviewed and simplified and that risk assessments inform and cross-refer to the care plan. Such a review has taken place and as a result, all information is readily and comprehensively recorded. The staff are commended on this achievement. It was recommended that care plans be signed by the person Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 10 writing these as well as by residents’ relatives/advocate. Wound care documentation has also been reviewed and now allows for easier audit. The possibility to delegate some care planning and review to senior care staff, following training, was discussed. Since the previous inspection, outdated exercise regimes on display in residents’ rooms have been removed and this information is now incorporated in the care plans. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 11 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): 12, 13, 14, 15, 16, 17. Residents are provided with opportunities for personal development and leisure both in-house and through outside activities. Residents are supported in maintaining good family links. Residents’ rights in their daily lives are respected Meals in the home are nutritious, varied and balanced. EVIDENCE: On the day of the inspection, several residents enjoyed playing games and a flexi fit session in the lounge and some residents had recently been shopping for Christmas presents. The home has a multi sensory (snoezelen) room and an art and craft centre. The home employs a physiotherapist. A physio-aid carries out a therapeutic exercise regime. The home shares a minibus with its sister homes which is used for trips out to the cinema, ten pin bowling, pub lunches and drives in the country. The home also has a number of other vehicles available. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 12 Two residents have recently been on holiday in Eastbourne. Many residents spend weekends and holidays with their families. Two relatives spoken to confirmed that the home welcomes family and friends and that they are encouraged to be involved in residents’ lives. From records completed by key workers, it is evident that they communicate well with residents’ families. Whilst some residents have soft or liquidised meals, some residents are fed through a tube (PEG). It was noted that staff assist the residents with their meals in a patient and dignified manner. Nutritional assessments are carried out. Residents are weighed regularly and if necessary, a dietician is available for advice and review. The inspector met with the cook in the kitchen who demonstrated a good knowledge of residents’ special dietary requirements. Menus seen evidenced that residents are provided with wholesome food, which includes fresh fruit and vegetables. Staff ensure that residents get plenty of fluids. Records of food provided are maintained. The home has recently been inspected by the EHO. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 13 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): 18, 19, 20, 21 Residents’ health needs are well met with evidence of multi-disciplinary input. Residents are provided with personal support to ensure that their physical and emotional needs are met. The home has a safe system for the administration of medication. Staff handle residents’ ageing, illness and death with sensitivity and respect. EVIDENCE: The home cares for residents with residential and nursing needs. Such needs are determined prior to admission by the funding authority and regularly reviewed during formal assessments whereby other specialists would be invited. District nurses meet the needs of those residents assessed as requiring residential care in accordance with an agreed protocol. Residents receive additional support from a multi- disciplinary team comprising physio, occupational and speech therapists and specialist nurses in respect of continence, diabetes, epilepsy and Huntington’s disease. Where needed, residents would be referred to orthopaedic consultants. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 14 It is evident that staff know the residents’ likes, dislikes and preferences very well. Staff have excellent communication skills and treat the residents with sensitivity, kindness and respect. Technical aids and equipment are provided to maximise independence and support. Special toilet chairs are provided and the majority of the bedrooms have overhead hoist. Due to their disability, the majority of the residents are dependent on a wheelchair tailor- made to their individual needs. Wheelchairs are maintained and their suitability reviewed by wheel chair specialists. It is evident that a multidisciplinary team cares for residents, which include physio, occupational and speech therapists, nutritionist and dietician. Residents are provided with individually assessed physio regimes. Medication administration charts were well maintained. Many residents have a complex medication regime, closely monitored and regularly reviewed. As identified at a previous inspection, the manager, in conjunction with the GP and pharmacist, has devised a protocol for the urgent delivery of an epilepsy medication and staff training provided. The subject of medication training resources for senior care staff was discussed. Staff are trained to care for residents with deteriorating health and palliative care needs. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 15 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, 23 Residents (through their family and advocates) know that their views will be listened to and acted upon Residents are protected from abuse and neglect. EVIDENCE: Since the last inspection, no complaints were received or recorded in the home’s complaints file. From discussions with the manager and other staff and confirmed by two relatives, it is ascertained that they speak to relatives regularly and inform and consult with them when any change in condition occurs. Any concerns expressed are dealt with immediately. Staff have excellent knowledge of and are trained in issues of adult protection. In respect of a reported incident, it was recommended that refresher training be offered in respect of challenging behaviour both in respect of protection as well as awareness of potentially “difficult” situations. The home has transparent policies and practices for dealing with residents’ monies. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 16 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, 30 The home provides a good standard of décor, which is homely, well maintained, spacious and safe. The gardens are well looked after and provided with seating arrangements. Residents’ bedrooms are personalised according to their lifestyle and equipment is provided to promote their independence. The home is clean and hygienic. EVIDENCE: The home is well maintained and decorated and has been specially designed for people with physical disabilities in respect of communal and bedroom sizes, corridors and door widths. These were in good decorative order. Bathroom fittings, equipment and overhead hoists are provided to promote independence. Equipment is replaced and serviced when necessary. Especially adapted en-suite toilets/showers and communal bathrooms are provided. The home provides a clean, hygienic and odour free environment. The deputy manager is the home’s infection control link nurse and has recently attended Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 17 training. Cleaning audits are undertaken six-monthly. Such an audit was carried out in November 2005. Carpets in the day areas were cleaned. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 18 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, 36 Staff have a good understanding of residents’ needs and residents benefit from a positive relationship. Staff turnover is low and residents benefit from an effective staff team. Staff are well trained and supervised. EVIDENCE: Staffing is stable with little changeover. Staffing levels indicate that these are adequate for residents’ needs. Several care staff have achieved the senior carer status with additional responsibilities. See also standard 6 in respect of care planning. As mentioned in the introduction, some relatives feel that, at times, there are not enough staff. This issue was discussed with the manager and director who took note. It was said that, at times, all staff may be involved with providing care in residents’ rooms giving the impression that there are not enough staff on duty. The director said he would address this perception and talk to staff and relatives. As evidenced on the training matrix, staff attend statutory, NVQ and specialist training. Several staff have achieved level 3 NVQ and the deputy manager has nearly completed NVQ 4 in management. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 19 Staff receive regular supervision. Some senior care staff, following training, are now involved with this process. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 20 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, 38, 39, 40, 41, 42 Residents benefit from a well run home. Residents’ views about the services provided are sought. The health safety and welfare of residents and staff is promoted and protected. EVIDENCE: The manager is supported by the director, a deputy and other staff. The deputy manager is currently undertaking NVQ 4 in management. Residents’ care needs are regularly reviewed both by the funding authority and in-house. Residents’ next of kin and/or advocate are always invited to take part. These reviews are well documented and detailed. Formal satisfaction surveys are undertaken twice a year and the results made available. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 21 The director produces a monthly quality audit in accordance with Regulation 26. The manager informs the CSCI of any reportable event as per Regulation 37. See also standard 23 in this respect. Health and Safety audits are carried out 4 times a year. Risk assessments are undertaken and accident records audited. All staff receive statutory training including moving and handling. Three members of staff are trainers in this respect. Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 22 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 3 x 3 x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 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 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bethany House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x DS0000023355.V257249.R01.S.doc Version 5.0 Page 23 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 Refer to Standard YA6 Good Practice Recommendations That care plans are signed Bethany House DS0000023355.V257249.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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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