Inspection on 10/05/06 for Bethany House Care Home

This inspection was carried out on 10th May 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 Care Home 07/06/07

Bethany House Care Home 11/01/06

Bethany House Care Home 08/08/05

Bethany House Care Home 01/03/05

Bethany House Care Home 04/08/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Bethany House Care Home Village Close Woodham Way Newton Aycliffe Durham DL5 4UD Lead Inspector Mr Leonard Hird Unannounced Inspection 10th May 2006 09:30 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 Care Home DS0000000698.V294241.R01.S.doc Version 5.1 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 Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bethany House Care Home Address Village Close Woodham Way Newton Aycliffe Durham DL5 4UD 01325 300950 01325 308897 susanfoster_25@hotmail.com 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) Object Quest Limited Mrs Susan Foster Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (5), Terminally ill (5) of places Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Physical disability over the age of 55. Persons with a physical disability, over the age of 55, may be accommodated, commensurate with the homes Statement of Purpose. Named Individuals: The home may accommodate named individuals as set out in a letter to the registered person dated 25 January 2006 which establishes the basis on which the individuals needs will be met by the home. Where necessary the home’s Statement of Purpose shall reflect any changes in service provision required for this arrangement. This condition may not apply to anyone else, other than the named individuals, who fall outside the registered category. 11th January 2006 Date of last inspection Brief Description of the Service: Bethany House is a registered residential care home providing nursing and personal care for up to 27 older persons. The home can also provide care for up to 5 persons with physical disabilities as well as up to 5 persons who are terminally ill within the overall registered number. The home is owned by Woodham Christian Centre Ltd. which is a charitable organisation managed by a Board of Trustees. The home is located in the town of Newton Aycliffe. The home was opened in 1992; it is a purpose built building providing residential and communal living space on two floors and the second floor can easily be accessed by the lift. There are 27 single bedrooms 4 of which have en-suite facilities. The home has an easily accessed conservatory, garden and courtyard area for the use of the residents and visitors. There are good public transport links to the local towns of Darlington, Shildon and Bishop Auckland. Local amenities including, a community centre, post office and a church are located nearby. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection of Bethany House with the assistance of the registered manager took place on May 10th 2006 between 0930 and 1500 hrs and considered all of the key standards as identified by the Commission for Social Care Inspection within the Care Homes for Older People National Minimum Standards. Key standards were assessed in the following areas: Choice of Home (NMS 3), Health and Personal Care (NMS 7, 8, 9 and 10), Daily Life and Social Activities (NMS 12, 13, 14 and 15) Complaints and Protection (NMS 16 and 18), Environment (NMS 19 and 26), Staffing (NMS 27, 28, 29, 30,) and Management and Administration (NMS 30, 31, 33, 35 and 38). There were some 10 written comments received from residents and relatives as well as 9 verbal comments received from residents and relatives on the day of inspection. Comments were also received from the manager and staff. What the service does well: What has improved since the last inspection? Since the last inspection the home has ensured that full and accurate records were being maintained of all medicine administration in accordance with guidance published by the Nursing & Midwifery Council. The home was now ensuring that Fire alarm tests were being carried out on a weekly basis and that staff were having the appropriate levels of fire drill training. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 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 Care Home DS0000000698.V294241.R01.S.doc Version 5.1 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 Care Home DS0000000698.V294241.R01.S.doc Version 5.1 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): NMS 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bethany House ensured that prior to admission prospective residents were assessed to ensure that the home could meet their current needs. EVIDENCE: Care plans contained the appropriate assessment undertaken by the local Social Care and Health Team along with an assessment undertaken by the homes manager. A relative spoken with during the inspection confirmed that their family member had received an assessment visit from the homes manager prior to their relative’s admission to the home. Bethany House does not offer intermediate care services. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 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): NMS 7 NMS 8 NMS 9 NMS10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual residents health, personal and social care needs were being clearly set out in their care plan. Residents were able to make decisions about how they could lead their lives and what level of assistance they needed. The homes medications policies, procedures guidance and training programme ensured that staff were able to dispense medication to residents safely. EVIDENCE: Residents living at Bethany House had individual plans of care in place and these detailed the individual residents health, personal and social needs. Individual care plans reviewed as part of the inspection process had been regularly reviewed and any identified changes of need arising from this review process had been appropriately actioned. Individual care plans covered important areas such as personal care, mobility and health requirements. Assessments of risk were also included in the plans and these assessments took account of the individual’s own views as well as their assessed needs. Records were being maintained by the home of the individual residents health needs as well as visits by doctors and other health professionals to the home. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 10 Written and verbal comments were received from relatives, confirming that the home tried wherever possible to keep them informed of the well being of their relative. A visiting relative also commented that the nursing and care staff kept a close eye on their family member and would call a GP to visit “ even if it was only for a precautionary measure”. There were well-established systems in place for the handling and recording of medication by both the nursing and care staff. Care staff involved in the administration of medication to residents had received appropriate training in the safe handling and administration of medication and this information was being maintained on their individual records. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS12 NMS13 NMS14 NMS15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living and activities available at Bethany House were varied and flexible and generally meeting the needs of the residents. Personal choice and independence of the residents was being promoted by the home. The dietary needs of residents were well catered for with a balanced and varied selection of food being made available to them. EVIDENCE: It was observed that the daily routines of living were flexible and meeting the needs of residents. One resident commented that they could take “their bath whenever they liked and help was always available from the staff ”. Residents also commented that they “could get up and go to bed whenever they wanted to and that staff would assist them accordingly”. Relatives visiting the home spoke highly of the homes visiting policy and one relative commented “they could come at any reasonable time to the home and were always made welcome”. Residents from Bethany House could access the local community centre and take part in the activities occurring there. Activities were also arranged for residents within the home. One resident spoken to said, “The food is very good and if you dont like what they give you it can be changed. ” A written comment received stated “ I Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 12 enjoy my meals, there is plenty of choice on the menu and snacks are available at all times” Menus were being displayed in the home of the different choices of food available and special diets were being catered for. Regular residents meetings were being held and the types and choice of food being made available on the home were regularly discussed. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 NMS18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Both the homes complaints and adult protection policy procedures, along with the training provided ensured that the residents were being protected from abuse and that there welfare was being promoted. EVIDENCE: The home had appropriate policies and procedures in place for the protection of vulnerable adults. Staff had received training on how to deal with the protection of vulnerable adults and records were being maintained of this training. In discussions with staff they confirmed that they were fully aware of the importance acting quickly in cases of suspected abuse and that they would follow the homes policy and procedures if a situation arose. The home also had appropriate policies and procedures in place and information was being displayed in the home on how to complain. Residents were aware of how and who to complain to. One resident commented, “that if wanted to complain they could and the manager would listen to them”. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS19 NMS26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Bethany House is clean, pleasant and hygienic and provides a safe and comfortable environment for its residents. EVIDENCE: Bethany House had been decorated and furnished to a pleasing standard and in the taste and style of the residents. One relative spoken with confirmed that they had helped choose the wallpaper and curtains for their family members room and that they had brought in different pieces of furniture to make it even more like home. A resident spoken with said, “The decoration and furniture in my room make it look lovely”. The communal living areas were well decorated and maintained. Records were being maintained of repairs and equipment maintenance within the home. Bethany House is clean, tidy and free from unpleasant odours. There were appropriate systems in place for infection control. The homes infection control policies and procedures were written in accordance with relevant legislation and professional guidance. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 15 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): NMS 27 NMS 28 NMS 29 NMS 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bethany House through its recruitment, employment and training procedures were ensuring that only suitably qualified nursing and care staff were employed. Staffing levels at the home were sufficient to meet the current assessed needs of the residents. EVIDENCE: From a review of the staff rota provided it was noted that staff were being deployed in sufficient numbers as to ensure that the needs of residents were being met. A written comment received from a resident stated that the “nursing staff were very good and were always around when needed “ There was a commitment to training for all staff at the home and by September 2006 over 90 of the care staff would be qualified at NVQ level 2 in care or above. Staff had being recruited in accordance with the homes policies procedures and all appropriate checks had been undertaken by the home prior to a member of Staff been employed. Staff had received appropriate induction training and there was an ongoing training programme operating in the home e.g. moving and handling, first aid training and working with dementia training. Records were being maintained of all training being given in the home and individual records of training were being kept on the staffs files. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 16 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): NMS 31 NMS 33 NMS 35 NMS 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bethany House has a very positive and well lead management structure ensuring that the home promotes the health, safety and welfare of both residents and staff EVIDENCE: There were clear lines of management, accountability and support systems to be found within the home. The manager provided support, guidance and direction for all of the staff. Staff spoken with confirmed this by comments such as “any training we need to help us to do the job was always made available” “the manager always has time to listen to us”. Formal supervision sessions were being given to all staff members including clinical supervision to the nursing staff. Records of staff supervision sessions were being maintained and staff confirmed that they had received copies of their own supervision. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 17 From discussions with staff it was confirmed that they were aware of the management structure within the home and that they could approach members of the management team at any time for advice and support. Comments received from residents, relatives and visitors during inspection were very positive; “staff were kind and considerate to their relative and nothing was too much trouble for them to do ” “the carers were always there to help and that they spent time talking to their relative” “the staff have become my family and Bethany House has become my home”. Residents and relatives spoken with were very positive in their comments on the way that the manager was always readily available to listen to them. Records were being kept of the regular residents meetings and the responses to the points raised by residents during these meeting from the manager were also being kept. Since the last inspection the home has ensured that the number of fire alarm tests and fire drills carried out has met the requirement made. Records were being maintained of when equipment had been serviced and who had undertaken and completed the work. Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 18 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 X 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 3 Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 19 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. 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. Refer to Standard Good Practice Recommendations Bethany House Care Home DS0000000698.V294241.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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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