Inspection on 11/01/06 for Bethany House Care Home

This inspection was carried out on 11th January 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 10/05/06

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 Mrs Pat English Unannounced Inspection 11th January 2006 10:00 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 Care Home DS0000000698.V283013.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.V283013.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.V283013.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical disability over the age of 55. Persons with a physical disability, over the age of 55, may be accommodated, commensurate with the home`s 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. 8th August 2005 2. Date of last inspection Brief Description of the Service: Bethany House is a care home providing personal care, nursing care and accommodation for 25 older people. Included in this total number the home provides care for up to 5 people with physical disabilities and up to 5 people who are terminally ill. The home is owned by Woodham Christian Centre Ltd. which is a charitable organisation run by a Board of Trustees. The home is situated in the town of Newton Aycliffe. Public transport links to Darlington Shildon and Bishop Auckland are good, and local amenities including, a community centre, post office and a church are conveniently located. The home was opened in 1992, it is purpose built providing accommodation on two floors and a shaft lift for ease of access. There are 23 single bedrooms one of which has en-suite facilities, and one double room with en-suite facilities and adequate communal facilities are provided on both floors. There is a garden and courtyard area accessible to wheelchairs. Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately four hours. The Manager assisted during the inspection and comments were received from five members of staff, seven visitors and eight residents. On this occasion the inspector looked at a total of nine core standards which were not assessed on the last inspection, these mainly concerned the Environment, Complaints, Management and Administration and Medication. What the service does well: What has improved since the last inspection? There were no requirements or recommendations from the last inspection. Bethany House Care Home DS0000000698.V283013.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.V283013.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.V283013.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): Standards assessed on the last inspection EVIDENCE: Bethany House Care Home DS0000000698.V283013.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): 9 & 10 Policies and procedures for dealing with medicines are generally satisfactory. However, the practice of failing to record all medication being administered is considered to be unsafe. Care practices in the home promote and protect residents’ privacy, dignity and independence. EVIDENCE: The home’s records for the receipt, recording, storage, handling, administration and disposal of medicines were all in place and were well organised and signed and dated correctly. However, it was noted in a small sample of resident’s records that some staff were failing to record when the medication had been administered. This meant that it could not be confirmed from the record, that the medication had been taken. The manager agreed to address this issue immediately. There were no residents who were able to take responsibility for their own medication. Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 10 All comments from residents and visitors confirmed that they were very satisfied with care practices within the home and staff were highly regarded for their respectful and caring attitude. Comments from staff indicated that they had a clear understanding of how to respect residents’ privacy Bethany House Care Home DS0000000698.V283013.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): These standards were assessed on the last inspection. EVIDENCE: Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18 Residents and relatives are confident that their concerns will be listened to, taken seriously and acted upon. The home’s policies and practices ensure that residents’ legal rights are protected and that they are safeguarded from abuse or harm. EVIDENCE: The home’s policies and procedures for the protection of vulnerable adults were satisfactory. The staff training programme included appropriate training courses in the safety and protection of vulnerable adults and it was evident that all staff were enrolled on these courses as a matter of priority. It was noted that the manager had recently been confirmed as a qualified trainer on the subject of abuse and will be arranging in-house courses on the subject. There have been no serious complaints to record. One minor concern had been recorded and the outcome was satisfactory. Comments from residents and visitors to the home confirmed that they felt able to express their views freely to staff. They said that the manager and staff were “always very helpful” and that they responded positively to any requests or queries they may have. Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 13 Residents and relatives were invited to periodic meetings held by the manager and staff where they were encouraged to give their views about matters concerning the home. Bethany House Care Home DS0000000698.V283013.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): 19 & 26 The standard of the environment within this home is good providing residents with an attractive, comfortable and safe place to live. EVIDENCE: The home is tastefully furnished and decorated in an attractive domestic style. Residents’ bedrooms were equipped to meet their individual needs and many had brought personal items with them to make their rooms homely and comfortable. Both residents and visitors remarked on how the home was “always very clean and tidy” and visitors said how they were “always made welcome”. There is an ongoing maintenance and refurbishment programme in place and the grounds are well maintained and safe. Recent improvements to the home have been the addition of two new single bedrooms with en-suite bathrooms which are equipped with aids and adaptations for people with disabilities. Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 15 The laundry and kitchen facilities were in good working order and it was noted that some new flooring and equipment had been purchased for the kitchen. There were satisfactory procedures in place for control of infection and the safe handling and disposal of clinical waste. Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 16 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): These standards were assessed on the last inspection EVIDENCE: Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 17 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 and 38 There is effective leadership, guidance and direction of staff to ensure that the home is run in the best interests of residents. Overall, practices within the home promote and safeguard the health, safety and welfare of residents and staff. EVIDENCE: There are clear lines of accountability within the home with the manager being supported by a team of qualified nurses. Comments from staff, relatives and visitors confirmed that relationships within the home were friendly and supportive. All the visitors remarked on how “friendly and welcoming” the manager and staff were, and that they were able to “come and go as they please”. Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 18 Care staff and nursing staff who gave their views commented on how they enjoyed working in the “homely and friendly atmosphere” of the home and that the home has “a good reputation” in the local community. All staff remarked on how there was “good communication and team work” and that they had “very good training”. Care staff also said that they had “fantastic” support from the manager and nursing staff. The manager continues to develop ways to seek the views of residents and relatives and these include a yearly survey and periodic meetings. Records of the residents’ meetings show that a variety of matters concerning the home are discussed including social activities and menus. A visitor and resident said how they had enjoyed the meetings. Residents’ personal finances were being handled satisfactorily. There was an ongoing maintenance programme in place for the servicing of equipment and maintenance of heating and electrical systems etc., and there was evidence from the maintenance contracts and service certificates that that the programme was kept up to date. However, records showed that the number of fire alarm tests and fire drills carried out in the home did not meet what was required under Fire Regulations and the manager agreed to take immediate action to address the shortfalls. Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 X 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 20 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 OP9 Regulation 13/17 Requirement To ensure that full and accurate records are maintained of all medicine administration in accordance with guidance published by the Nursing & Midwifery Council Fire alarm tests must be consistently carried out on a weekly basis Fire drills must be carried out in compliance with Fire Regulations i.e. day staff must have 2 drills in a year and night staff must have 3 drills in a year Timescale for action 11/01/06 2 OP38 23 11/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Bethany House Care Home DS0000000698.V283013.R01.S.doc Version 5.1 Page 22 - 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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