Inspection on 03/10/06 for Bethany House

This inspection was carried out on 3rd October 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 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 01/11/05

Bethany House 26/04/05

Bethany House 18/01/05

Bethany House 04/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Bethany House Gamull Lane Ribbleton Preston Lancashire PR2 6TQ Lead Inspector Ms Susan Dale Unannounced Inspection 10:00 3 October 2006 rd X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bethany House DS0000009839.V304626.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 DS0000009839.V304626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethany House Address Gamull Lane Ribbleton Preston Lancashire PR2 6TQ 01772 792226 01772 792226 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Preston Bethany Trust Mrs Gillian Whitfield Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 27 service users in the category of old age, not falling in any other category (OP) over 65 years of age The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 1st November 2005 Date of last inspection Brief Description of the Service: Bethany House is a Residential Care Home for the Elderly, built and managed by Preston Bethany Trust, a Christian Charity (Registration No. 511535). The home provides personal care to older persons over the age of sixty-five years and is purpose built and the accommodation for service users is all on the ground floor. The home has been extended and now has the benefit of a large 2nd lounge and an easily accessible patio area. The home is situated within its own grounds, close to local shops and other community facilities. Accommodation is available for long term, short term, and respite care for Service Users with physical, medical, spiritual and social needs. Assistance is provided to enable each service user to follow their religious faith within the home and encouragement to participate in a local church of their particular denomination. Terminally ill Service Users needing nursing care or with Alzheimers disease are not accepted for accommodation, but should a Service Users condition deteriorate during their stay, every effort would be made to assist them using outside agencies. Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was unannounced and the focused mainly on key standards. The inspector was able to speak to service users and staff and examine various records. Comment cards were provided to service users, relatives/friends and health professionals prior to the inspection. 11 comment cards were returned from service users or their representative and 6 comment cards were returned from service users/relatives. All the responses were very positive and the results were taken into account as part of the inspection. A tour of the premises took place. What the service does well: All the service users who completed comment cards indicated that they felt well cared for and were treated well by the staff. Relatives also spoken with commented on how well the service users are treated, comments included: “We the family, are very happy with the home. She is very happy living within Bethany House and she is happy with the service etc. We are grateful for all she receives.” “I have no regrets whatsoever in coming to Bethany. There is a warm and caring atmosphere and company when we feel the need, or privacy when that is wanted. There is freedom in living here.” The home is well supported by the local community with visitors from local churches and schools. Visitors are encouraged and can have a meal with service users. The home has a very welcoming atmosphere and the surroundings are pleasant with plenty of space for communal activities or for a quiet corner when preferred. The meals are served in very pleasant surroundings and there were many compliments about the food, comments included: “A menu is displayed every day for dinner and tea. If you don’t like the menu there is always an alternative offered.” Staff spoken to feel appreciated by management staff and well supported in their role. A team approach is taken over the care of service users and the wishes and care needs of the service users come first with regard to the policies and procedures operating within the home. Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 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 DS0000009839.V304626.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 DS0000009839.V304626.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&3 The quality in this outcome group was good. This judgement has been made using available evidence including a visit to this service. Up to date written information about the home is available and each service user is provided with the terms and conditions/contract when they commence. Prospective service users are assessed in order to ensure that the services provided meet their needs. EVIDENCE: Since the last inspection a new manager has been registered with the Commission for Social Care Inspection and the documentation, which provides information about the care home to prospective service users, has been updated. A full assessment is undertaken before service users are admitted to the home; a visit is undertaken to the prospective service user at home or in hospital to confirm whether they will be able to meet their needs. The assessment is comprehensive and looks at any particular physical requirements such as the need for specialised equipment or whether there are Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 9 any risks connected with their care needs; also included within the records was a checklist for preparing and checking the new service user’s room. The manager is currently assessing the pro-forma used for recording the initial assessment and care plan in order to improve the existing records. Also included within the records was a checklist for preparing and checking the new service user’s room. Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 10 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 & 10 Quality in this outcome group was good. This judgement has been made using available evidence including a visit to this service. A comprehensive care plan is produced that meets all physical/health and emotional requirements and appropriate medication policies and procedures are in place. 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. The following comment was made by a relative: “Staff are always approachable and they are pro-active initiating Doctor referrals or additions to her care plan.” Care plans seen took into account the physical and emotional needs of the service user. The manager is currently examining the current pro-forma Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 11 together with the staff in order to improve the documentation. Some advice was provided in ensuring that enough background information is obtained to with regard to social interests and hobbies are met as much as possible within any physical restraints. There was evidence that a review is carried out of the care plan once a month and a detailed `Progress Record’ is maintained. Appropriate medication policies and procedures are in place for the storage, handling and administration of Medicines. There is a dedicated storage area for medication, which is kept secure at all times. The manager provides oversight to ensure that medication records are complete and signed for at the time of administration. 6 staff are responsible for the provision of medication and have received training. Evidence was provided from observation, comment cards and talking to service users and staff that privacy and dignity are respected at all times. Comment cards also indicated that the service users felt well cared for and were treated well by the staff. Service users confirmed that they receive their mail unopened and a public telephone is available for use as well as one within the office to ensure privacy. Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 12 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 & 15 Quality in this outcome group was good. This judgement has been made using available evidence including a visit to this service. Appropriate activities are in place according to the needs and capabilities of the service users. Contact is maintained with family, friends and the local community. EVIDENCE: 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 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. One of the staff is in charge of activities and has been provided with time to ensure they take place once a fortnight. A file is created that records the activities, who has participated and feed back from individual service users. Activities have included ‘painting pigs’ as well as outings to the Blackpool illuminations with a fish and chip supper. Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 13 Good contact is maintained with family and friends and regular visits, usually every Tuesday, are undertaken by representatives from local churches. Service users confirmed that meals offered variety and choice and that they are provided at regular intervals. There were 11 comment cards returned from service users who all confirmed that they liked the food. Menus are planned on a two weekly rota and cater for any service user on a specialised diet. Mealtimes were seen to be unhurried and assistance provided discreetly. One service user spoken to prefers to have meals in her bedroom because she has problems eating due to arthritis in her hands. Relatives provided the following comments: “Staff give individual time sometimes and encourage involvement in what is going on i.e. Church services and occasional days out.” “If you don’t like the menu there is always an alternative offered.” Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 14 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 & 18 Quality in this outcome group was good. This judgement has been made using available evidence including a visit to this service. There is an appropriate procedure for dealing and recording any concerns about the care and facilities of the home. Polices and procedures are in place for protecting service users from abuse. EVIDENCE: The home has an appropriate complaints procedure and Complaints, Compliments and Comments leaflets are freely available. There have been no complaints received by the Commission for Social Care Inspection. 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. Some 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 any new 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 DS0000009839.V304626.R01.S.doc Version 5.2 Page 15 Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 16 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 & 26 Quality in this outcome group was good. This judgement has been made using available evidence including a visit to this service. The home is clean and well maintained. All areas of the home including service users’ personal accommodation are safe, clean and comfortable. EVIDENCE: The home and grounds are safe, accessible, and well designed for the needs of the service users. Every effort has been made to ensure that the decor is of a high standard. The building complies with the requirements of the fire service and environmental health department. A tour of the premises took place and the home was found to be warm, clean and free from any obvious hazards. One service user made the comment: “A lot of effort is made in keeping the home clean.” In the new extension, doorways and corridors are wide and suitable for wheelchairs. Lighting within the rooms is domestic in character and sufficiently Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 17 bright for a variety of interests and activities. New bedrooms have the facility of a large en-suite consisting of a toilet and hand basin. A refurbishment programme is in place as any service users leave and rooms become available; wardrobe doors are being replaced and basins are being retiled. Approximately 6 bedrooms have recently been decorated as well as the small lounge. All the doors leading to the service users private accommodation are to be replaced to be the same as those in the new extension with self closing features in the event of a fire. An additional hoist has been purchased and ‘sit on’ weigh scales. Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 18 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 & 30 Quality in this outcome group was good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff on duty for the needs of the service users. A suitable recruitment procedure is in operation that ensures the protection of vulnerable people and training is provided to staff that ensures they are competent and able to meet the needs of the 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. Staffing rotas were provided that show there are sufficient numbers of staff on duty at all times and service users and a relative spoken to confirmed that they had no concerns over the staffing levels. There were 6 comment cards returned from the relatives or friends of service users who stated that when they had visited the home there were sufficient numbers of staff on duty. There are currently 26 care staff and 7 have obtained an NVQ qualification, there are a further 6 care staff in the process of obtaining an NVQ qualification. As well as Induction Training, evidence was provided that a staff-training programme is in operation that meets National Training Organisation Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 19 specifications. All staff have recently been provided with ‘in house’ First Aid and basic Food Hygiene training. Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome group was good. This judgement has been made using available evidence including a visit to this service. The home is well run and service users benefit from the services provided by the staff. Service users are also protected by the policies and procedures operating within the home. EVIDENCE: The manager has recently been appointed to the home and undergone registration with the Commission for Social Care Inspection. Evidence was provided to show that the manager has recently successfully completed an NVQ level 4 in Health and Social Care and is about to commence the NVQ level 4 Registered Managers award top up programme. Staff meetings are held on a regular basis at which minutes are taken and daily meetings are held to discuss any issues that have arisen. The chairman of the home’s board of trustees visits the home on regular basis and speaks to service users and staff and the information gathered is then fed back to the Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 21 staff within the home. Staff meetings are held on a regular basis at which minutes are taken and daily meetings are held to discuss any issues that have arisen. 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. The chairman of the home’s board of trustees visits the home on regular basis and speaks to service users and staff and the information gathered is then fed back to the staff within the home. There is a need for the chairman to provide a report once a month to the Commission for Social Care Inspection under Regulation 26 of the Care Homes Regulations; a report has not been received since the 10th April 2006. Staff confirmed that the manager is very supportive and service users spoken with were very happy with the attention they received from both manager and staff. A relative made the following comment: “The manager of the home is always available to discuss any problem and they work at correcting it whatever it may be.” There was evidence that staff receive individual supervision at least six times a year. Supervision covers all areas of practice and the philosophy of care within the home. All other staff are supervised as part of the management process. A new approach is now taken with regard to staff duties with a form entitled ‘Staff duty and Breaks Rota’. The senior completes the form the day before and records the duties of each staff rotared for duty particularly with regard to tea breaks and cleaning. A ‘handover sheet’ is completed as necessary for issues with regard to individual service users. The manager ensures that the health, safety and welfare of service users and staff are promoted as is reasonably practicable. Staff training is provided in all key areas. The home has appropriate Health and Safety policies and a qualified contractor services the boilers and electrical systems. Windows are fitted with restrictors and there is an intruder alarm system. Risk assessments are in place in relation to safe working practices throughout the home. Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 22 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X X X X X 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 X 2 Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 26 Requirement A report must be sent to the Commission once a month following a visit to the home by the Registered Person to inspect the conduct of the home. Timescale for action 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations NVQ training of care staff should continue. Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bethany House DS0000009839.V304626.R01.S.doc Version 5.2 Page 25 - 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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