Inspection on 18/05/06 for Bethel & Bethesda Residential Home

This inspection was carried out on 18th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Bethel & Bethesda Residential... 31/10/07

Bethel & Bethesda Residential... 29/09/05

Bethel & Bethesda Residential... 28/06/05

Bethel & Bethesda Residential... 24/11/04

Bethel & Bethesda Residential... 28/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Bethel & Bethesda Residential Home Equity Road East Earl Shilton Leicestershire LE9 7FY Lead Inspector Kim Cowley Unannounced Inspection 18th May 2006 12:30 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 Bethel & Bethesda Residential Home DS0000001817.V292438.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. Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bethel & Bethesda Residential Home Address Equity Road East Earl Shilton Leicestershire LE9 7FY 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) 01455 847505 01455 850042 Cooper Residential Homes Limited Mrs Judith Anne Wright Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Previous Authority. The home may accommodate a named person who falls within the category Sensory Impairment SI(E) as named in the previous authority records dated 18th March 2002. 29th September 2005 Date of last inspection Brief Description of the Service: Bethel and Bethesda is a residential care home for older people. It is close to the centre of Earl Shilton where there is a range of shops and other local amenities. The home caters for 34 residents. All bedrooms but one are single and 21 have ensuite facilities. There are four lounges, two dining rooms, two kitchens, and a secluded courtyard garden. The premises are single-storey and all areas are accessible to residents with limited mobility. Fees range from £311 to £319 per week. Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included a visit to the home and inspection planning. Prior to the home visit, the inspector spent half a day reviewing the last inspection report, and information relating to the home received since that inspection. During the course of the inspection, the inspector checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called case tracking. Case tracking means that the inspector looked at the care provided to three residents living at the home by talking with the residents themselves; talking with the Owners and the Manager and staff who support their care; checking records relating to their health and welfare; and viewing their personal accommodation as well as communal living areas. Other issues relating to the running of the home including health and safety and management issues were inspected. Five other residents were also interviewed. What the service does well: Bethal and Bethesda offers excellent care to residents in a clean and wellmaintained environment. All residents interviewed praised the home and the following comments were made: ‘I’m very impressed with this home.’ ‘I feel very lucky to be here.’ ‘I’ve got everything I need here – what more could a person want?’ ‘This home agrees with me!’ ‘It’s lovely here and everybody’s so kind and helpful.’ ‘This home suits me.’ ‘It’s a very good place here. The food’s good and the staff are nice.’ Staff were observed as treating residents with respect. One resident commented, ‘No one’s taken my dignity away here. It’s drummed into the staff to respect us. No-one every comes through my door without knocking.’ Another said, ‘The cleaner is very respectful – she said to me “Do you mind if I look in your cupboard to see if you’ve enough toilet rolls.” That was very polite of her.’ Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 6 The Owners and Manager are supportive of the staff team and encourage them to increase their skills and gain qualifications. This results in better care for residents. All residents interviewed praised the staff team. The following comments were made, ‘If you ask for something the staff get it straight away’, ‘The staff are very good and very kind to us’, and ‘I cannot praise the staff enough. They are wonderful.’ The home was commended for the following: care plans, treating residents with respect, the staff team, the staff training programme, the premises and their cleanliness, and the quality assurance system. What has improved since the last inspection? 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. Bethel & Bethesda Residential Home DS0000001817.V292438.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 Bethel & Bethesda Residential Home DS0000001817.V292438.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ needs are assessed prior to admission to ensure the home is suitable for them. EVIDENCE: All potential residents are encouraged to visit prior to admission. They can either come for a short visit and have lunch, or have a period of respite care. The Manager assesses them before they come to the home, either in hospital or in their own homes. The Manager also sees their comprehensive social services assessment if they have one. Once in the home they have a four-week trial and staff said they are under no obligation to stay if they don’t want to. Two named senior carers are responsible for admitting new residents. They ensure all the required paperwork is in place and liaise with the resident and their relatives during the admission process. Any queries can be addressed to them. Bethel & Bethesda Residential Home DS0000001817.V292438.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): 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Health and social care professionals help residents to maintain and improve their physical and mental health. EVIDENCE: Senior carers in consultation with the Manager write care plans. Once complete they are read to residents and/or their relatives who are asked to sign them if they are in agreement. Care plans are reviewed at least once a month and updated where necessary. A designated senor carer has responsibility for this task. Care plans are of good quality being comprehensive and detailed and showing evidence of residents being involved in decisions about their care. The home’s care plans are commended. Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 10 Risk assessments are completed on admission and evaluated monthly. Residents or their relatives are asked to sign risk assessments to show they are in agreement with them. A medical audit is carried out for each resident on admission. Domiciliary visits are organised for optical and dental services. A GP does a surgery in the home every Wednesday. District Nurses visit when necessary and work with staff to meet care needs. Two private chiropodists visit the home on request and charge £10.00 per session. Residents can be referred to NHS chiropodists if they wish. Only seniors are authorised to administer medication and all have completed a ‘Safe Handling of Medication’ course with a local college. In addition the home’s contract pharmacist inspects medication systems every three months. If there are any concerns about a resident’s medication their GP is contacted and asked to review it. At present no residents self-medicate, although the Owners said they are encouraged to do so where possible. Staff are trained to treat residents with dignity and respect during their ‘First Steps’ induction. This lasts six weeks and covers the principles of good care including privacy, dignity, and choice. The Owners said all staff are observed in their interactions with residents and their performance discussed during supervision. When residents come into the home they are asked to complete a ‘Residents Preferences’ form which sets out their likes and dislikes, including terms of address and personal care routines. One resident commented, ‘No one’s taken my dignity away here. It’s drummed into the staff to respect us. No-one every comes through my door without knocking.’ Another said, ‘The cleaner is very respectful – she said to me “Do you mind if I look in your cupboard to see if you’ve enough toilet rolls.” That was very polite of her.’ The staff are commended for the respectful way they treat residents. Bethel & Bethesda Residential Home DS0000001817.V292438.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): 12, 13, 14, 15 The quality outcome for this area is good. This judgement has been made using the available evidence including a visit to the service. Daily life and social activities enable residents to lead full lives. EVIDENCE: Residents from a range of religious background live in the home including Anglicans, Methodists, and Roman Catholics. Regular church services are held in the home and some residents go out to local places of worship. One staff member is available one morning a week to provide activities for residents. Card making has become popular and residents make cards for birthdays, Christmas, and other occasions. Four residents have started their own domino school at the home. Residents go to a local club to watch indoor bowls. Residents’ hobbies and interests are recorded on ‘social activity sheets’ in their care plans. Regular activities include bingo, coffee mornings, trips out in staff cars (which are insured for business use), walks, slide shows, and clothes parties. Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 12 Residents’ comments about the activities included: ‘We’ve been making birthday cards – I enjoyed that.’ ‘We had a residents’ meeting. We talked about the activities we’d like and staff said they’d try and arrange them for us.’ ‘I go to church every week.’ ‘We have communion here in the home.’ Visitors are welcome at the home at any time and can see residents in their bedrooms or in communal areas. The home employs two full-time cooks. Winter and summer menus are produced. Menus showed a wholesome and varied diet being offered. The home has two kitchens (one for the preparation of main meals, and the other where snacks are made). Residents eat in one of two dining rooms. Breakfast is cooked or continental. Lunch is the main meal of the day and there is always a choice of main course. Tea is hot and cold snacks and homemade cakes and biscuits. The home caters for diabetics and will provide vegetarian food on request. Since the last inspection chalkboards have been put up in the dining rooms so residents can see what is on the menu each day. Partially sighted residents are told verbally what the choices are. Residents’ comments about the food were all positive. One resident said, ‘We have traditional good solid English food.’ Another commented, ‘The food is beautiful, there’s nothing I’ve not liked.’ Bethel & Bethesda Residential Home DS0000001817.V292438.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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents feel able to talk to staff about any concerns they might have. EVIDENCE: The home’s complaints procedure is made available to all residents and relatives. A framed copy is also on the wall in the reception area. Any complaints made are recorded in a complaints book along with the action taken to resolve them. Records showed that all complaints, however minor, are taken seriously and addressed. Residents have the opportunity to raise issues of concern at residents’ meetings. One resident said, ‘At the end of residents’ meetings we are asked if we have any complaints.’ Another commented, ‘It is impressed on us at residents meetings that we must say if we have any concerns.’ Policies and procedures are in place to protect residents from abuse. Staff receive training on adult protection during their TOPSS induction and must sign to say they have read and understood the home’s policies and procedures. The home has a copy of the updated ‘No Secrets’ guidance. This has been discussed at staff meetings to ensure staff know how to protect residents. Bethel & Bethesda Residential Home DS0000001817.V292438.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Residents live in an environment that is safe and well maintained. EVIDENCE: The purpose-built premises are comfortable and homely. There are numerous pictures and ornaments throughout the home, some donated by the families of past residents. There is a range of lounges so residents can choose where they sit. The premises are commended. Improvements to the premises since the last inspection include; • • • One kitchen redecorated and a new floor covering laid A new boundary fence One dining room redecorated DS0000001817.V292438.R01.S.doc Version 5.1 Page 15 Bethel & Bethesda Residential Home • Four bedrooms redecorated A member of the Owners’ family oversees maintenance and redecoration and contractors carry out any work that needs to be done. A maintenance book is kept and records show an ongoing programme of improvement. If a bedroom is vacated it is usually redecorated and refurbished for the next occupant. The premises are risk assessed once a month and detailed records are kept of this. A contract gardener maintains the gardens. The home and grounds are wheelchair accessible throughout. There is a range of moving and handling equipment including bath hoists, an oxford hoist, patient handling belts, and slide sheets. The home employs four part-time cleaners. All areas inspected were clean, fresh, and tidy. The cleanliness of the home is commended. Bethel & Bethesda Residential Home DS0000001817.V292438.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): 27, 28, 29, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Friendly, professional, and well-trained staff meets residents’ needs. EVIDENCE: Records showed that staff turnover in the home is low. The staff team is established and some members have worked at the home for many years. The Owners said it is seldom necessary to recruit new staff, but when the home does proper procedures are followed and checks carried out. These include a requirement for two written references (one of which must be from the candidate’s most recent employer) and enhanced CRB clearance. All new staff work under supervision and have a three months trial period. A programme of formal staff supervision is in place. This includes an annual appraisal and six further supervision sessions. The latter are task-based and comprise of an assessment of a member of staff carrying out a specific role, for example giving personal care, bed making, or serving meals. These supervisions are linked with NVQs to enable staff to gain qualifications as they work. Records showed that staff are offered a wide range of training opportunities. NVQs are established in the home and 57 of staff have NVQ Level 2 or above. Seventeen members of staff are qualified first aiders. Training in basic Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 17 literary skills is given to staff where necessary. Staff supervisions are linked with NVQs to enable staff to gain qualifications as they work. The staff team is multicultural. Staff who have English as a second language are given extra support from a tutor at a local college to help them improve their language skills. The Owners and Manager are supportive of the staff team and encourage them to increase their skills and gain qualifications. This results in better care for residents. All residents interviewed praised the staff team. The following comments were made: ‘If you ask for something the staff get it straight away.’ ‘It doesn’t mater what you ask for – the staff will try and get it. They can’t do enough for us.’ ‘The staff are very good and very kind to us.’ ‘I cannot praise the staff enough. They are wonderful.’ The staff team and the staff training programme is commended. Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 18 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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a home that is safe and well managed. EVIDENCE: The Registered Manager has 21 years experience in care. The Owners are equally experienced and are fully involved in the day to day running of the home. Residents meetings are held every two to three months and give residents the opportunity to air their views about the home, raise issues, and make requests Record keeping and administration systems are of a high standard and are another indication of how well run this home is. Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 19 The home has a ‘Quality Management System for Care Homes’ in place. This allows staff to review all standards and identify if improvement is needed. A senior carer has been given responsibility for issuing quality questionnaires to residents and relatives. In April 2006 21 residents were issued with questionnaires and all 21 were returned completed. The information was then presented in the form of pie charts and the findings shared at a residents’ meeting. One of the Owners said, ‘This was a useful exercise. For example, we discovered that only 27 of residents were aware of the Residents Charter. To address this we produced a large print version of the charter and put it on the residents’ notice board.’ The home looks after small amounts of money for some residents who are not able to look after it themselves. Residents or their representatives sign an agreement if they want this arrangement. Appropriate records are kept. Staff at the home do not get involved in any other aspect of residents finances. These are handled by relatives themselves or by their relatives/representative. If staff have any concerns about how a resident’s finances are being managed social services are involved. Polices and procedures are in place for safe working practices and staff receive appropriate training. A designated person oversees the maintenance of the building and carries out a monthly audit/risk assessment. On a day-to-day basis staff use a maintenance book to record areas in need of attention. Contractors do the servicing and maintenance of appliances in the home. The home’s Fire officer visited on 22.07.05 and recommended the home’s Fire Risk Assessment was re-written on a standard form. This was done and the Fire Officer approved it when he again visited on 7.12.05. Records showed that a new fire alarm is due to be fitted in June 2006. The Environmental Health Officer inspected the home on 4.05.06 and requested that a new kitchen floor covering be fitted. This has been done. Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 20 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 4 8 3 9 3 10 4 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 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 21 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 Bethel & Bethesda Residential Home DS0000001817.V292438.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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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