Inspection on 08/08/05 for Bethany House Care Home

This inspection was carried out on 8th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 11/01/06

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 DL5 4UD Lead Inspector Pat English Unannounced 8 August 2005 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 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 B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bethany House Address Village Close Woodham Way Newton Aycliffe DL5 4UD 01325 300950 01325 308897 Telephone number Fax number Email 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 25 Category(ies) of OP Old age - 24 registration, with number PD Physical disability - 5 of places TI Terminally ill - 5 Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Persons with a physical disability, over the age of 55, may be accommodated, commensurate with the homes statement and purpose of function. Date of last inspection 1st March 2005 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 B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately four hours and the manager, RGN (qualified nurse) and two care staff, two relatives and five residents were spoken to and gave their views. On this occasion the inspector looked at a total of 12 standards under Choice of Home, Health and Personal Care, Daily Life and Social Activities and Staffing. What the service does well: What has improved since the last inspection? There have been some positive improvements in the variety and content of the activities programme particularly in promoting residents’ spiritual as well as mental and physical wellbeing. There is a dedicated member of staff who organises and plans the activities and who is well regarded for her skills in this area of care practice. There are regular planned meetings held for both residents and relatives to air their views and be involved in making decisions about life within the home and choice of menus, activities, outings etc. The manager takes these meetings seriously and ensures that they are recorded in detail together with her responses to any suggestions, comments etc. Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 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 B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 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 standard(s) 3, 4 and 5 The home’s admission procedures are being strictly followed and prospective residents have their needs assessed by qualified people prior to entering the home to ensure that the home can adequately meet their needs. Assessments are comprehensive and recorded in good detail to ensure that staff in the home have all the relevant information they need. EVIDENCE: Individual records are kept of each resident and sample of these records were inspected. Residents had been appropriately assessed by qualified people prior to their admission to the home and had a full assessment of their needs recorded including risk assessments. It was noted that the assessment documentation was very comprehensive and covered all aspects of health, mental health, personal and social care needs and identified areas of risk. An additional nursing needs assessment was also provided for one resident who had been admitted from hospital. One of the recent admissions had been in an emergency and records showed that all the appropriate documentation had been received. The manager stated that social and health care professionals work closely with the home throughout the admission process and this has meant they “work together” and this helps the admission process to run smoothly. Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 9 Each resident’s file was in good order and clearly set out and the information recorded was detailed and dated and signed appropriately. Where possible, residents and their relatives were included in the assessment process and visited the home prior to admission. The staff rotas showed that the number of registered nurses on duty was adequate for the nursing needs of the home. Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents’ needs. The health care needs of residents are well met and there is good evidence of the home consulting and involving health care professionals in the community on a regular basis. EVIDENCE: Each resident’s care plan was generated from their needs assessment and identified all aspects of their health including any clinical needs, mental health, personal and social care needs. The information recorded was in good detail and where areas of risk had been highlighted, risk assessments clearly specified the action to be taken to meet the assessed needs. Reports were kept of each resident’s daily progress and their needs were reviewed on a monthly basis with records of these reviews being kept updated to reflect any changing needs. Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 11 Residents’ personal files held records of formal reviews and visits carried out by social workers and these showed that formal reviews were done on a regular annual basis and included the residents and family members in the process where possible. Specific records were being kept of any involvement or intervention from health care professionals and these included detailed assessments carried out by Chiropodists and Opticians; the records showed that the home was taking the necessary measures to promote and maintain residents’ health care needs. It was noted that a high focus was being put on what residents eat and detailed nutritional assessments were being recorded on each resident as part of this initiative. The manager stated that all staff in the home were currently attending specific training on the subject of nutrition and how this is linked to residents’ health and wellbeing. Comments received from residents during the inspection confirmed that they were aware of their care plans and were involved in making any decisions about their care. They said they were “well looked after”, “very satisfied” and “staff are very good”. Relatives visiting also confirmed that they were involved in any decision making and that they could “discuss anything at any time” and “could not fault the care”. Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 to 15 Social activities are well organised, creative and provide stimulation and interest for residents in the home. The manager ensures that both residents’ and relatives’ views are sought when planning menus, activities and social events and that they are involved in making decisions in a constructive and pro-active way. EVIDENCE: The home has a dedicated member of staff who is the “activities organiser” for planning a programme of recreational, religious and social activities on a weekly basis. There have been a number of positive improvements in the variety and content of the activities programme and these take residents’ abilities into consideration and allow for chatting and discussion. There are stimulating activities such as knitting, “pamper days” which include hand creaming and massage, manicure, hairdressing etc., “news report” days where daily newspapers are read and discussed and “music and video nights” with ice cream and stacks. There are also plans for residents to do “exchange visits” between local care homes which would allow them to meet and chat over tea and coffee. The manager and staff said that the activities have much improved under the activities organiser who is “very popular with residents” and “good at her job” and that residents were already benefiting from her input. Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 13 Information on each resident’s social, religious and recreational interests and a brief life history was being recorded in their assessment records. A monthly social diary is kept of each resident’s progress in participating in activities and residents/relatives’ meetings are held on a regular basis. Records of these meetings show that there is a broad agenda for discussion and residents/relatives are asked for their views and suggestions on the food, activities, outings, facilities etc. The records show that their comments are taken seriously and that the manager responds to them all in writing. The residents’ suggestions on food have been taken into account when planning menus which are now placed on the tables for their information. Menus show that a balanced and nutritious diet is provided with plenty of choice. Due to the home’s “Focus on Food” training initiatives there are nutritional assessments done on each resident and these are subject to ongoing review. The majority of residents and visitors who have their views were satisfied with the food and one remarked that it had improved. The home’s strong links with the church were evident through the regular visits by the local clergy and lay people of all denominations and weekly services are held within the home one of which was a “children’s service” held very recently. A garden Gazebo had been set up for residents and visitors to sit in the sunny weather and the manager stated it was proving to be very popular. Comments from residents and visitors confirmed that they always felt welcome in the home and that the staff had a “sense of humour” as well as being “polite and caring”. Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed EVIDENCE: Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 15 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 standard(s) Not assessed EVIDENCE: Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 The home benefits from a competent, well trained and well managed workforce who work positively with residents to improve their quality of life. EVIDENCE: A check on the records of latest member of staff employed confirmed that recruitment procedures were being followed correctly and satisfactory references and employment history with an explanation for any gaps had been obtained. This addresses a requirement from the previous inspection. All staff employed in the home had undergone a satisfactory criminal records bureau check. The home has almost achieved the minimum ratio of 50 trained members of care staff with a National Vocation Qualification (NVQ) level 2 with a total of 8 out of 17 care staff having achieved the qualification, 2 of whom have the level 3. The manager stated that 3 care staff were currently training for their level 2 and 3 more for their level 3. There is a stable workforce with a number of staff having worked in the home a long time and others who have left and returned. The number of qualified nursing staff and care staff on duty remains consistent and there were no issues raised over staffing levels during this inspection. Comments from staff indicated that there is good morale and team work and that they are well supported by the manager and the qualified nursing team. Catering and domestic staffing arrangements were satisfactory. Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 Page 19 Are there any outstanding requirements from the last inspection? 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 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. Refer to Standard Good Practice Recommendations Bethany House Care Home B54 SN698 Bethany House SN232431 080805 stage 2.doc Version 1.40 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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