CARE HOMES FOR OLDER PEOPLE
Bethany House 20 Front Corkickle Whitehaven Cumbria CA28 8AA Lead Inspector
Colette Hibbert Unannounced Inspection 8th December 2005 09:00 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.V269479.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 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.V269479.R01.S.doc Version 5.0 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.V269479.R01.S.doc Version 5.0 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 7th June 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. Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced commencing at 09:00 and finishing at 15:30. The inspection involved meeting and talking with residents and their families and reading care plans. Staff were observed at work and spoken with, as were the manager and the providers. Visiting relatives and professionals were also spoken to. A tour of the building and the grounds was carried out. There were 13 residents living in the home and 3 vacant rooms, staffing levels were appropriate for the number of residents What the service does well: What has improved since the last inspection?
The home has decorated both the lounge areas and new carpets have been fitted which has created a bright relaxing homely environment for the residents. Two residents room have been decorated and the residents are pleased with them. Radiator guards have been fitted to provide a safer environment for the residents. This was a requirement at the last inspection and has been met. The registered manager is now doing the pre admission assessment so that the residents can be sure the home can provide for their needs. Bethany House DS0000052971.V269479.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 DS0000052971.V269479.R01.S.doc Version 5.0 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.V269479.R01.S.doc Version 5.0 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 Residents are well supported by staff to make informed decisions about choice of home. They are given the opportunity to visit to find out if their care needs can be met. Each resident has a written contract to provide them with information about the services they will receive in the home. EVIDENCE: The registered manager of the home carries out the pre-admission assessment to enable a decision to be made as to the care requirements of the resident and if the home is able to met these needs. Residents and families confirmed that they had visited the home prior to admission. One resident said she had looked at another home and chosen this one .She felt she had made a good choice. The residents are given contracts / terms and conditions, a copy is kept in the care plan, stating what services the home could provide for them. There were no residents that were outside the categories of the home registration. Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 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): 7,11 There was a clear care plan in place for each resident enabling the staff to identify residents care needs. Residents’ wishes at time of death were documented and residents felt this was a comfort and that staff would follow these. EVIDENCE: The registered manager had spent a lot of time renewing the care plans, they were found to be more person centred and identified the residents care needs. Residents had been involved in this process, so that they were able to state personal preferences. They provided comprehensive information for the staff to work from and had been reviewed recently with changes in residents care needs highlighted. Community nurses said that the home had just suffered the loss of a resident; they felt that the staff had cared for the resident with respect and the person was treated with dignity. Staff spoke about the resident with affection and said they felt they had lost a family member. The staff felt they supported the resident, family and each other well. Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 Page 10 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): This standard was fully inspected at the last inspection and met. EVIDENCE: Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 Page 11 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 There was a clear complaints procedure and the residents were aware of how to make a complaint. They felt it would be dealt with in an appropriate manner. Staff were aware of the protection of vulnerable adults policy and knew what steps to take to keep the residents safe within the home. EVIDENCE: There have been no complaints since the last inspection. Families spoken to said that the staff were very approachable and felt they would be able to make a complaint if they needed to .One relative said that she would go and see the manager and ‘that the problem would be sorted out straight away’. Since the last inspection there had been an incident within the home, the Management had followed correct procedures by notifying Social Services, Protection of Vulnerable Adults Team and CSCI. The home has carried out its own investigation and the issues are being addressed for the welfare and protection of the residents. Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 Page 12 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): 20,21,23,24 and 25 There were areas both inside and outside of the building that raised cause for concern regarding the safety of the residents and the staff. The home had sufficient bathroom facilities to provide appropriate care to met the resident’s needs. The kitchen, laundry facilities and storeroom in the basement were in need of up grading to make a better and more efficient working facility. Storage of equipment is a problem and needs to be addressed to provide a safe, uncluttered environment for the residents. All bedrooms were single occupancy and residents had personalised them to there own taste. EVIDENCE: On the day of the inspection the electrician was fitting new electronic alarms to the external door of the building. This will improve the residents’ safety within the home. Outside at the back of the building in the grounds the residents could be at risk as there is a steep drop over the low garden wall, the owners agreed and said that they would fix a gate at the side of the building and railings along the garden wall to keep the residents safe.
Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 Page 13 The two lounge areas had been redecorated and carpeted and they were homely, bright and pleasant for the residents and their families to sit in. The residents said they liked their rooms, one resident was very keen to show me her family pictures, and the staff had put names on as she kept forgetting ‘who was who’. Radiators had been fitted with covers throughout the home to ensure a safer environment for the residents. This had been a requirement on the last inspection and has been met. The storeroom area in the basement was used for storing cleaning products. The door was propped open giving easy access to the products, some of which had been left open. There was no lock on the door and residents may be at risk from ingesting hazardous substances. The laundry was also untidy and used as a store for broken equipment. The walls were in need of painting. Some improvement had been made to the kitchen with new work units fitted providing a clean preparation area for the meals. The fly screen on the back door was dirty and had holes in it allowing insects into the kitchen. This needs to be replaced to ensure high standards of hygiene were residents’ meals are being prepared. Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 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 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): 28,and 29 The home had a thorough recruitment policy to safeguard the residents within their care. EVIDENCE: The staff group is a stable one with many of the staff having worked within the home for a number of years. The staff spoken to enjoyed working in the home, and that they had received training and regular supervision, which improved the quality of care they could offer to the residents. The staff files supported this. A new member of staff was working during the morning and she had a structured induction. References, CRB and POVA checks were all in place to secure the safety of the residents. Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 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 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): 34,35 and 36 Key workers help those residents who are not able to shop for themselves. The staff receive supervision on a regular basis, which enables them to progress and develop their role to provide a high standard of care for the residents. EVIDENCE: The manager said that residents’ finances were managed by social services and if residents needed anything key worker would do the shopping. Receipts were then submitted. The residents were happy with the system one resident said that she only had to mention something and ‘her member of staff would bring it in’ The staff are given regular supervision and it is documented within the staff files. Several members of staff were spoken to. They were given notice when supervision would take place so that they could prepare for it. They felt it gave them an opportunity to develop there role within the team, highlight any
Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 Page 16 training they felt they needed and so improve the care they could give to the residents. Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 Page 17 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 3 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X 3 3 X X 3 2 X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 3 X X Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 Page 18 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. Standard OP19 Regulation 23.2b Requirement A renewal and maintenance plan must be submitted to CSCI to include the redecoration of the home, how storage will be addressed and when planned alterations are expected to commence. (This is an outstanding requirement 01/02/05) The ground are made safe with gates and railings fitted The ground floor back corridor must be repaired and decorated Storage of equipment must not effect the residents living area The responsible individual must send a monthly report to CSCI on the operations of the home. (This is an outstanding requirement with a timescale for action of 28.02.04) Chemical cleaning fluid must be safety stored. Timescale for action 31/01/06 2 3 4 5 OP19.1 OP19.2 OP22.7 OP37 23.2b 23.2b 23.2i 26 31/01/06 31/03/06 31/01/06 08/02/06 6 OP38.3 13.4i 31/12/05 Bethany House DS0000052971.V269479.R01.S.doc Version 5.0 Page 19 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.V269479.R01.S.doc Version 5.0 Page 20 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
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