Inspection on 07/06/07 for Bethany House Care Home

This inspection was carried out on 7th June 2007.

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 10/05/06

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 Mrs Sue Lowther Unannounced Inspection 7th June 2007 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.V337069.R03.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 Care Home DS0000000698.V337069.R03.S.doc Version 5.2 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) of places Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 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 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. 10th May 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 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. The fees charged at the time of this inspection were between £360 and £576. These fees do not include hairdressing, newspapers and private transport. Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Bethany House took place on the 7th June 2007. Records were examined and a tour of the building took place. Time was spent talking to service users, staff and relatives. The manager supplied some information on a pre inspection questionnaire. The inspection focussed on key standard outcomes for service users. What the service does well: What has improved since the last inspection? What they could do better: The computerised record keeping system needs to be kept under review to make sure that records are easily accessible to staff, the people who live in the home and their relatives. This is to make sure that the people who live in the home are aware of the care they can expect to receive. Care plans also need to be available to staff so they know how to look after people on an individual basis. Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Bethany House Care Home DS0000000698.V337069.R03.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 Care Home DS0000000698.V337069.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care and therefore assessment of Standard 6 is not required. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment procedures are in place to ensure that the home can meet all of the needs of the people who go to live there. EVIDENCE: Everyone is assessed before they go to live in the home. In addition to social service care manager assessments the manager normally visits the person in their current place of residence. She advised the inspector that she would sometimes take another person with her if she feels this is needed. If she were on holiday this would be done by one of the nurses. Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 9 The files of three people recently admitted to the home were found to contain comprehensive information. The family confirmed that they had looked around the home and had been supplied with all of the information they needed to make a decision about whether or not their relative would like to live there. One person said, “The manager came to our home and gave me all of the terms and conditions. I then came to visit. There was plenty of information available”. Two other people confirmed that they were given all of the information that was needed to make a decision about whether they would like to live in the home. Bethany House Care Home DS0000000698.V337069.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good systems are in place to ensure that health care needs of the people who live in the home are met. People can be confident that their privacy and dignity is protected and that they are treated with respect. EVIDENCE: Each person has a care plan in place to cover health and personal needs. This makes sure that all of the staff know how to look after people on an individual basis. Since the last inspection the home have started to store these on a computer. Staff can access these and show them to the people who live in the home. The manager said that this system was working well. This needs to be reviewed regularly to make sure people can access their records when they need to. This is to make sure that people know about the care they can expect to receive. Care plans also need to be available to staff so that they know how to look after people on an individual basis. Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 11 One relative said, “The staff and manager are very good and very helpful. Staff phone me all of the time when there is any change they think I need to know about”. All of the people spoken to confirmed that they receive the medical support they need. One person said, “If I am poorly I tell the staff and they would get the doctor in”. Evidence was seen in files of involvement with other people for example district nurses, doctors, and care managers to confirm that other professionals are involved. The medications of four people were checked and found to be in order. People said that staff treat them with dignity and respect. They said that staff always knock on bedroom doors and call them by their preferred name. One person said, “ The staff talk to me nicely and with respect”. Bethany House Care Home DS0000000698.V337069.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities are varied and provide recreation for some of the people living in the home. Family and friends can visit the home at any time and are made to feel welcome. The meals are of a good standard. Menus are varied and service users are given a choice. EVIDENCE: Most of the people said that activities are suitable. The people who live in the home made comments such as “Activities are available but I prefer to do crosswords”. “I like to get involved in everything that goes on”. Relatives said that they could visit at any time and that they are always made welcome. One said, “I can come and go anytime and I am always made to feel welcome. People said that they have a choice about how they like to spend their day. They can also choose what time to get up and go to bed and when they would like to have a shower or bath. One service user said, “I can get up and go to Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 13 bed when I want. I can have a bath when I want. When I want to go out staff will take me”. The lunch looked nice. One person said, “ The meals are good and you get a choice”. A visitor said, “The food is very good. I come here for mine every Sunday”. Bethany House Care Home DS0000000698.V337069.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home can be confident that their concerns and complaints are dealt with appropriately and that safeguards are in place to protect them from abuse. EVIDENCE: Information about complaints, how and who to make them to, is made available to people through information displayed in the entrance to the home. It is also in the ‘Service Users Guide’. One person said, “If I had a problem I would tell the manager and I know that she would sort it out”. One relative said, “I would approach the manager but I have never had any need to complain”. There were four complaints recorded in the home since the last inspection. These have been appropriately addressed using the procedure available within the home. Views are obtained through regular contact and an ‘open door policy’. Residents meetings are held to discuss any concerns or potential difficulties. Resident Surveys have also been carried out within the home. Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 15 The home has detailed adult protection procedures. Copies of these were seen to be available for staff use. Staff interviewed voiced a commitment to the people they work with and to upholding the rights of the people who live in the home. One member of staff confirmed that he knew about the procedure with regard to safeguarding adults. He said that he would have no hesitation in reporting any incident where he suspected someone was being abused. Bethany House Care Home DS0000000698.V337069.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and in the main, well maintained. It is decorated and furnished to a good standard and provides a homely environment for the people who live there. EVIDENCE: During the tour of the building and whilst talking to people in their bedrooms, the inspector saw that people could bring in their own furniture and belongings should they wish to do so. There is an ongoing programme of redecoration to make sure the environment is homely. All of the bedrooms are single, some have a shower and toilet. There are sufficient additional bathroom and toilet facilities available. Some bedrooms also have specialist overhead tracking which helps staff to look after people Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 17 who have difficulty in moving. However some of the flooring in the communal toilets needs to be replaced to provide a more homely environment. The manager said that this work was due to be carried out soon. During the tour the inspector found the building to be clean, tidy and free from offensive odours. Bethany House Care Home DS0000000698.V337069.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a settled and well-led staff team in sufficient numbers to meet the needs of the people who live in the home. EVIDENCE: The off duty rotas supplied with the pre inspection questionnaire indicated that there are a minimum of five staff duty throughout the day and three during the night. There is at least one qualified nurse on duty at all times. Comments made by people in the home about staff included “The staff are always available. They are always around to talk to me”. Another said, “The staff are very good, they are always available”. The home had staff files in place, which provided evidence that the appointment of a new staff member is made through proper recruitment processes. This includes the vetting of staff through the use of references, POVA first checks and Criminal Record Bureau (CRB) checks. There is a commitment at the home to having a trained workforce and a variety of training courses are available to all staff. A high proportion of care staff are trained to NVQ (National Vocational Qualification) in care at level two or above. Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 19 Recent training has taken place in the falls awareness, protection of vulnerable adults, fire safety awareness and moving and handling. Staff confirmed that there is always sufficient training available to provide them with the skills and knowledge they needed to look after the people in the home. Bethany House Care Home DS0000000698.V337069.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a registered manager who provides support and guidance to staff and the people who live in the home. Policies and procedures are in place to safeguard health, safety and wellbeing. EVIDENCE: There was an open and friendly culture between the management team and the staff at the home. Staff said that they felt well supported in their work and evidence in staff files confirmed that regular supervision of staff takes place and that staff are appraised. The people who live in the home and their relatives confirmed that the manager is approachable and that they would go to her if they had any concerns. Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 21 Regular meetings are held and the company have a number of systems in place to consult service users. The company carries out a quality assurance audits on a regular basis. This covers all aspects of care delivery and environmental issues. Copies of these were available in the home. The manager is responsible for the record keeping with regard to the finances of people who live in the home when they are unable to look after their own. She was able to identify the amount that each person had in his or her account. The records for two people were checked and found to be in order. It is recommended that a second person audit these accounts on a regular basis to ensure that the people are protected. The manager confirmed that all equipment in the home is regularly checked. The maintenance certificates seen at this inspection were found to be in order. Bethany House Care Home DS0000000698.V337069.R03.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 X X 3 X X N/A 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.V337069.R03.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP19 OP35 Good Practice Recommendations The computerised records system needs to be regularly reviewed to make sure it is easily available to staff and the people who live in the home. The flooring in some of the toilets should be replaced to provide a more homely environment. It is recommended that a second person carries out an audit with regard to the finances held by the home to protect the people who live there. Bethany House Care Home DS0000000698.V337069.R03.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V337069.R03.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. 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