Inspection on 26/04/05 for Bethany House

This inspection was carried out on 26th April 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 01/11/05

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 PR2 6TQ Lead Inspector Susan Dale Unannounced 26 April 2005 10:00 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 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 F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bethany House Address Gamull Lane, Ribbleton, Preston, Lancashire, PR2 6TQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01772 792226 01772 792226 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 F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 180105 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 Alzheimer’s 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 F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over three hours. The inspector was able to speak to the registered manager, staff, service users and a relative and visitor to the home. A partial tour of the home was conducted and various records were examined including service user and staffing records. What the service does well: What has improved since the last inspection? A large extension has been built that includes a separate lounge as well as 12 additional bedrooms and a bathroom. The exterior has been improved with an attractive patio area that includes a water feature that is easily accessed from the new lounge. The facilities also now include separate staffing accommodation, a staff room and various other rooms that could be used for a variety of purposes including staff supervision and training. Storage areas have also been provided with a dedicated storage area for medication and an additional bathroom and sluice. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 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 F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 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 standard(s) 3 & 5 There is a waiting list for the home and prospective service users have every opportunity to visit the home as frequently as they wish and participate in daily activities until they are certain that the home will meet their individual needs. An initial assessment is undertaken that takes into account the physical, spiritual and emotional needs of the service user as well as any potential risks. EVIDENCE: Service users and relatives spoken to confirmed that a flexible approach is taken allowing prospective service users to visit the home prior to making a decision about permanent residency. The records of 3 service users were examined and found to contain and initial assessment that detailed all the service users requirements and their situation prior to requiring residential care. The assessment also looked at any particular physical requirements such as the need for specialised equipment, for example, wheelchair or hoist, and any risks that may be connected with their care needs. Also included within the records was a checklist for preparing and checking the new service user’s room. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 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 standard(s) 7, 8 & 9 A thorough initial assessment leads to the compilation of an effective care plan that takes into account the physical and emotional requirements of the individual. EVIDENCE: The records seen were well laid out and each section was divided into sections covering the assessment, risk assessment and care plan General Practitioners/District Nurses etc visits, hospital appointments and telephone calls were recorded in a separate section and were very detailed showing that good liaison was in place with all health practitioners. A care plan had been devised that took into account the physical and emotional needs of the service user and all areas as listed in standard 3.3 of the Care Home Regulations, hobbies and interests had been recorded and how this area could be met whilst residing in the home. There was evidence that a review is carried out of the care plan once a month and a detailed `Progress Record’ is maintained. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 Page 10 A relative confirmed that she had been involved in the compilation of the care plan for her mother who did require an advocate and that she had been very impressed with the care provided and that it was a “home from home”. There is a section within the records for all possible risks to be recorded some of the recordings seen could be improved by a little more detail. The format for recording the care plan does have a space for a signature of the person recording the care plan and the manager was advised that a signature should be obtained where possible from service users or their relatives/advocates. At the last inspection there were a number of requirements and recommendations with regard to the provision of medication. At the current inspection there was evidence that all the requirements and recommendations had been met. There is now a dedicated storage area for medication, which is kept secure at all times. The manager is providing oversight to ensure that medication records are complete and signed for at the time of administration. All staff have received training in medication. Patient Information Leaflets are being obtained and kept in a file. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 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 standard(s) 12 &13 The lifestyle of the service user prior to entering the home is taken into account and facilities are in place to ensure that their expectations and preferences are met as much as possible in all aspects of their lives. EVIDENCE: Evidence was provided from talking to service users that the routines of daily living are flexible and varied according to individual needs. Service users interests are recorded and there are ample opportunities for religious interests, leisure and recreational activities both inside and outside the home. Information about activities is circulated verbally as well as documented on a notice board. At the time of the inspection a weekly meeting with music and singing was taking place with a representative from one of the local churches and the daughter of a service user was playing the organ. Video evenings take place on alternate Saturdays and although there has been a lack of interest in any trips out, there is a hope that the trips will commence again as the weather turns warmer. Written information about visitors is contained within the Statement of Purpose and Service User Guide. Links with the local community are maintained by visits from the local schools and talks provided by local community groups. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 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 standard(s) 18 Policies and procedures are in place to ensure that service users are protected from abuse. EVIDENCE: The home has comprehensive procedures in relation to dealing with allegations of abuse. Staff policies include the need for the non-involvement of staff with regard to legal documents/wills and the non-acceptance of gifts. All staff are made aware of these policies during their induction period and are asked to sign documentation confirming they have read and understood the content of the policies. All the regular staff have received training on the subject of Adult Abuse and Whistle Blowing as part of their NVQ training. A recommendation was made that some in-house training on the home’s procedure in the event of any Abuse would be beneficial for staff. The recruitment procedure ensures that prospective staff are checked as to whether they are on the Protection of Vulnerable Adults Register (POVA) as well as Police clearance via the Criminal Records Bureau. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 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 standard(s) 19 &20 The home has undergone considerable improvements very recently to both inside and outside communal areas for the benefit of both service users and staff. EVIDENCE: A large extension has recently been completed that includes additional bedrooms, a large lounge, additional bathroom and sluice, a staff room and additional rooms that can be used for a variety of purposes. The lounge also includes easy access to a new patio area with a water feature. Prior to the extension, the dining room was attached to the lounge and there was no defined area for staff to have training or individual supervision. The carpets, furniture and fittings are new and of very good quality and the doorways and corridors are wide and suitable for wheelchairs. Lighting within the rooms is domestic in character and sufficiently bright for a variety of interests and activities. Each additional bedroom has the facility of a large en-suite consisting of a toilet and hand basin. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 The home has an appropriate recruitment policy and procedure that ensures the protection of service users. EVIDENCE: Staff files were examined including the details of staff recently appointed to work within the home. Two written references had been received prior to commencement and clearance had been obtained from the Criminal Records Bureau and a check undertaken of the Protection of Vulnerable Adults Register (POVA). All staff have to abide by a Code of Conduct that is in accordance with the code set by the General Social Care Council. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 34 Every effort is made to ensure that the service users are happy with the services provided by the home and have the opportunity to comment about the way the home is being managed. The home and business is protected by suitable accounting procedures and insurance. EVIDENCE: Questionnaires are distributed once a year to service users and a separate questionnaire once a year to relatives and friends. The results are analysed and distributed for everyone to see. Meetings are held 4 times a year between all the members of the board to discuss and review any issues and discuss the future. Bethany House has been awarded 4 stars in a Benchmarking exercise instigated by Lancashire County Council. The home is covered is covered by suitable insurance. Suitable accounting and financial procedures are in place to ensure the home’s financial viability. Meetings are held 4 times a year by members of the board to look at existing and future costs and maintain a business plan. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x 3 3 x x x x Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 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. 1. 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. Refer to Standard 7 18 Good Practice Recommendations Staff should be provided with training to ensure that a comprehensive risk assessment is carried out and recorded on the care plan. In-house training on the procedure to follow in the event of any Adult Abuse should be provided to all staff. Bethany House F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Unit 1, Tustin Court Portway 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 F57 F09 S9839 Bethany House V217366 260405 Stage 4.doc Version 1.30 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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