Inspection on 28/06/05 for Bethel & Bethesda Residential Home

This inspection was carried out on 28th June 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

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

Bethel & Bethesda Residential... 18/05/06

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

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

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

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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 Tuesday, 28th June 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. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bethel & Bethesda Residential Home Address Equity Road East Earl Shilton Leicestershire LE9 7FY 01455 847505 01455 850042 None Cooper Residential Homes Limited 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) Mrs Judith Ann Wright Care Home 34 Category(ies) of OP Old Age - 34 registration, with number of places Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: To admit one named service user in the category Sensory Impairment over 65 years of age SI(E) as identified in correspondence with the previous registration authority dated 18th March 2002. To admit one named service user in the category Sensory Impairment over 65 years of age SI(E) as identified in variation number V9153. Date of last inspection 24.11.04 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 and all the bedrooms but one are single. Twenty-one of the rooms have ensuite facilities. There are four lounges, two dining rooms, two kitchens, and a secluded courtyard garden. All areas of the home are fully accessible to service users with limited mobility, and the premises are single-storey. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on a weekday. The inspector met with nine residents, two of the care staff, and the two Owners (the Manager was on leave). The premised were toured. Care records were examined. There were no requirements outstanding from the last inspection, and no new requirements were made. Care plans and the premises were commended. Prior to the inspection a total of 11 Comment Cards from Relatives/Visitors and Social Workers were returned. All respondents said they were satisfied with the overall care in the home. One Social Worker wrote, ‘I have consistently found this home offers a very good standard of care, tries to resolve individual problems by adapting the arrangements in the home, and offers a happy and comfortable environment to residents.’ What the service does well: Bethel and Bethesda provides good quality care for residents in a homely environment. All residents interviewed many positive comments about the home and staff. One resident commented ‘This is a very good home. I wouldn’t want to be anywhere else.’ Records show that residents care needs are identified and met. Detailed care plans are produced which residents (or their relatives) sign to show they agree with them. Residents’ hobbies and interests are recorded on ‘social activity sheets’ in their care plans. Regular activities are provided including bingo, coffee mornings, trips out, walks, slide shows, and clothes parties The home employs two full-time cooks. Winter and summer menus are produced. They showed a wholesome and varied diet being offered. Residents’ comments about the food were all positive and included, ‘The food is beautiful’, and ‘I’m always happy with the food.’ The purpose-built premises are comfortable and easily accessible to residents with mobility problems. All areas inspected were clean, fresh, and well decorated and maintained. Residents’ comments about the premises included, ‘I love my room and so do all my relatives’, and ‘It was lovely to come here and see all my things in my room.’ The staff are friendly and professional knowledgeable about the needs of the residents they care for. Residents praised the staff and their comments Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 6 included, ‘The staff look after us well here – I’ve got nothing to complain about’, and ‘The staff are marvellous – I can find no fault with them.’ 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 C51 S1817 Bethel & Bethesda V235757 280605.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 Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.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, 5 Residents’ needs are fully assessed prior to their admission. They are welcome to visit the home and stay for a trial period. Residents with particular needs are properly cared for. 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. At present the home caters for two partially sighted residents. Their care was discussed and staff explained that their bedrooms were set out so they are Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 9 easy to access and staff assist them around the home. Staff have previous experience in caring for blind and partially sighted residents. Records showed that these residents’ needs are identified and met. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.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, 8 Care plans are of good quality and show evidence of residents being involved in decisions about their care. Residents’ health care needs are met following an audit. EVIDENCE: Six residents’ files were inspected. Each contained care plans, risk assessments, medical information, daily records, admission notes, medication information, social services reviews, and general correspondence. Care plans are written by senior carers in consultation with the Manager. 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. This commended. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 11 Since the last inspection all risk assessments have been reviewed and updated and new ones put in place where necessary. Risk assessments are now 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. Residents’ files have been re-located since the last inspection and are now kept in a locked filing cabinet in the reception area. Senior carers have keys to this filing cabinet. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.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, 13, 14, 15 Regular and varied activities are provided to suit residents’ needs. Visitors are made welcome at the home and have a choice as to where they see residents. Two full-time cooks provide a varied and wholesome diet, which was praised by all the residents interviewed. EVIDENCE: 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. Thirteen residents recently attended a four-week watercolour painting course with a visiting tutor. Communion is held in the home once a month. Visitors are welcome at the home at any time and can see residents in their bedrooms or in communal areas. During the inspection a number of visitors were observed coming and going. Some visitors were seen sitting outside with residents in the shade under awnings. Visitors are encouraged to join in social events at the home. The home recently hosted a 100th birthday party for a resident, which was attended by 35 visitors (the relatives and friends of the resident). Another similar party is being planned for another resident. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 13 Residents’ meetings are held approximately six times a year. The home’s receptionist takes the minutes. There is an average attendance of 15 residents at each meeting. Past minutes showed that residents speak out at these meetings and raise any concerns they might have. Minutes are passed to the home’s management who meet with the residents’ sub-committee (consisting of a chair and three other residents) to discuss action to be taken. 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. The home caters for diabetics and will provide vegetarian food on request. Residents’ comments about the food were all positive and included: ‘The food is beautiful.’ ‘We have wonderful puddings.’ ‘I’m always happy with the food.’ Staff said there had been some problems with the catering but these had now been resolved, and there are new cooks and new menus. Minutes of residents’ meetings showed that residents have made suggestions to improve the menus and these had been acted on. For example, residents had asked for more salads and these have been provided. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.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) 16, 17, 18 The home’s complaints procedure is readily available to residents and relatives. Staff are trained in protecting residents from abuse. 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. The Owner said that residents also have the opportunity to raise issues of concern at residents’ meetings. She said ‘At the last residents’ meeting it was stated that the plates were cold at mealtimes. In response we acquired a hostess trolley and we now use this to warm the plates.’ 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. The Owner said this will be discussed at the next staff meeting. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.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) 19, 26 The premises are comfortable and homely. All areas inspected were well maintained and in good decorative order. The home is clean, fresh and tidy throughout. 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. 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. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 16 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. Residents’ comments about the premises were all positive and included: ‘I love my room and so do all my relatives.’ ‘My (relative) is so happy to see me comfortable here.’ ‘It was lovely to come here and see all my things in my room.’ Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 17 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 The staff team is effective and residents are satisfied with the care they receive from them. EVIDENCE: Those staff interviewed were friendly and professional and in discussions were found to be knowledgeable about the needs of the residents they care for. Residents made many positive comments about the staff including: ‘The staff are smashing.’ ‘The staff look after us well here – I’ve got nothing to complain about.’ ‘The staff encourage me to walk.’ ‘The staff are marvellous – I can find no fault with them.’ Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 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 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) These Standards will be inspected at the next inspection. EVIDENCE: Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x x x x x Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 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 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 12 Good Practice Recommendations It is recommended that the activity programme is reviewed to see if activities should be increased and residents encouraged to spend more time outdoors. Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 Page 21 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Bethel & Bethesda Residential Home C51 S1817 Bethel & Bethesda V235757 280605.doc Version 1.40 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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