Inspection on 02/02/06 for Bethel Care Home

This inspection was carried out on 2nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bethel Care Home 09/10/08

Bethel Care Home 12/10/06

Bethel Care Home 05/09/05

Bethel Care Home 08/03/05

Bethel Care Home 19/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Bethel Care Home 41-43 Tennyson Way Hornchurch Essex RM12 4BU Lead Inspector Ms Gwen Lording Unannounced Inspection 2nd February 2006 08:30 Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 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 Care Home DS0000027882.V281186.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 Adults 18-65. 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 Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bethel Care Home Address 41-43 Tennyson Way Hornchurch Essex RM12 4BU 01708 620 985 01708 475 300 afopeace@aol.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) Mrs Mary Modupeola Omeyele Afolabi Mrs Mary Modupeola Omeyele Afolabi Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That at all times there must be a minimum of one member of staff in each house. That the night staffing levels must be maintained at one member of staff sleeping in and one member of staff on waking night duty. 5th September 2005 Date of last inspection Brief Description of the Service: Bethel Care Home is a care home providing accommodation and support for adults with a learning disability. The proprietor is also the registered manager of the home. In October 2005 Bethel and the separately registered home next door, Beaulagh Lodge were registered as one service. The home is now registered to accommodate up to six residents, three in each house. The home is situated in a quiet cul de sac in a residential area of Hornchurch. The area is close to public transport, local shopping area and other amenities. All six bedrooms are single and located both upstairs and down stairs. The home is friendly and operates as a ‘family’ type home. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 8.30am. It took place over five hours during the morning and early afternoon. Discussion took place with the proprietor/ registered manager and three members of care staff. The Inspector spoke to two residents and was able to communicate with one other resident with the help of staff. A tour of both homes was made and a number of care and staff records were looked at. This was the second statutory inspection visit in the inspection programme for 2005/2006. Over the course of the two visits, all key standards have now been assessed. The Inspector would like to thank the staff and residents for their input during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Areas where the home could do better were discussed and agreed with the proprietor/ registered manager. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 6 The decoration and general maintenance within both houses needs to improve to make the home more comfortable and safe for the residents. This issue has been raised in previous inspections. The registered person must produce a planned maintenance and renewal programme for the fabric and decoration of both houses. A written copy of the programme must be provided to the Commission, which includes timescales and areas highlighted for priority action. There has been no progress in the requirement for all staff working in the home to receive training in Adult Protection/ Abuse Awareness and this must be complied with by the new timescale. All verbal/ telephone references undertaken for staff prior to employment must be followed up in writing. 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 Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 The Statement of Purpose and Service User Guide provides prospective residents and their relatives all the information they need to make an informed choice about whether they wish to live in the home. Standards 2 and 3 were not assessed on this visit. However, evidence from the last inspection was that: • The assessments completed by the home and the information and reports received from other health and social care professionals means that staff have detailed information to determine whether or not the home can meet a prospective resident’s needs. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to Standards 2 and 3. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. At the previous inspection a requirement was made for the Statement of Purpose and Service User Guide to be amended to more accurately describe the communal facilities and the philosophy of the home. The description of the service has also been amended to include reference to the recent changes in the registration of the home. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7. Staff provide residents with information, assistance and support to enable them to make decisions about their own lives. Standards 6, 8 and 9 were not tested on this visit. However, evidence from the last inspection was that: • Care plans are detailed and provide staff with the information they need to satisfactorily identify and meet residents’ personal, social support and health care needs. EVIDENCE: The above standard was not specifically tested on this visit, as there were no outstanding requirements in relation to this standard. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Residents require varying degrees of support with their finances. At the last inspection a requirement was made that where support is needed, the reasons for, and the manner of support must be clearly documented in the individual’s care plan and regularly reviewed. The Inspector was able to evidence that this requirement has now been met. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 10 Staff were observed providing residents with information, assistance and support and were respectful of their right to make decisions. The home is run as a ‘family’ home. Meals, activities, house routines and house issues are discussed on a daily basis and al members of the home are fully involved. Information is displayed in the lounge about the advocacy service HavCare with a photo of the advocate who visits the home. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 17. Residents are provided with varied and nutritional meals, staff promote healthy eating and individual preferences are catered for. Standards 12, 13, 14, 15, 16 and 17 were not assessed on this visit. However, evidence from the last inspection was that: • Opportunities for social, leisure pursuits and personal development are actively promoted and supported by staff for all residents to enable them to participate in the wider community in which they live. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 were not tested on this visit. However, evidence from the last inspection was that: • The residents physical and emotional care needs are closely monitored and this ensures that resident’s needs are recognised and met. • The medication policies and procedures are clear and staff have received training to ensure the safe administration of medication to residents. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 23 There has been no progress in all staff working in the home receiving training in Adult Protection/ Abuse Awareness to ensure a proper response for reporting any suspected or witnessed abuse. Standard 16 was not tested on this visit. However, evidence from the last inspection was that: • The home has a satisfactory complaints system in place and residents and their relatives feel that their views are listened to and acted upon. EVIDENCE: The above standard was not specifically tested on this visit, as there were no outstanding requirements in relation to this standard. At the time of the last inspection, all of the outcome standards were assessed as met. This standard will be re-tested at a future inspection. There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. Some staff have received training in Adult Protection/ Abuse Awareness. A requirement was made at the last inspection for all staff working in the home to receive training in Adult Protection/ Abuse Awareness and this has not been progressed. It is a requirement that this is considered to be a priority training need for all staff in the home and must be complied with by the new timescale. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 26, 27 & 30 The overall atmosphere in both houses is very welcoming and some improvements have been made since the last inspection. However, there are still a number of areas in the home requiring re-decoration and re-furbishment, so as to provide residents living in both houses with a well-maintained environment. EVIDENCE: Both houses were toured at the start of the visit, and all areas of both houses were visited accompanied by the proprietor/ registered manager later during the day. Some bedrooms were seen either by invitation of the residents, whilst others were seen because the doors were open or rooms being cleaned. All areas of the home were clean, tidy and free from odour throughout. A number of requirements were made at the last inspection for areas in the home requiring repair or replacement. The registered person has taken action to address the following: • Bedroom One: Bedroom carpet has been purchased and is scheduled to be fitted within the next two weeks. Wardrobe door has been replaced and curtain track repaired. The window frames have been re-painted. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 15 • • • • Bedroom Two: Broken chair has been replaced. Upstairs bathroom: Mirror, shower curtain replaced. New carpet has been ordered for the stairs and hallway in House one (41). Downstairs Shower Room/ Toilet: Damp areas have been treated, but treated areas now need to be made good. The proprietor/ registered manager must produce a planned maintenance and renewal programme for the fabric and decoration of both houses. A written copy of the programme must be provided to the Commission, which includes timescales and areas highlighted for priority action. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 & 35 The home’s recruitment policies are not being consistently followed and may result in residents receiving care from staff members who have not been properly vetted. Standards 33 and 36 were not tested on this visit. However, evidence from the last inspection was that: • Staffing levels are satisfactory and there is sufficient staff on duty to meet the individual needs of the residents. EVIDENCE: The above standard was not specifically tested on this visit, as there were no outstanding requirements in relation to this standard. At the time of the last inspection, all of the outcome standards were assessed as met. This standard will be re-tested at a future inspection. When the two homes were registered as one service in November 2005, a condition of registration was imposed that the night staffing levels be increased to one member of staff sleeping in, and one member of staff on waking night duty. The Inspector was able to evidence that this condition of registration is being complied with. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 17 The duty rota was seen and this concurred with the names of the staff on duty. The registered person must ensure that the actual hours worked by staff each day is recorded and not just LD – long day. In discussion with staff it was evident that they understand and fully support the main aims and values of the home. Staff files showed that some staff had done essential training in first aid, food hygiene and moving and handling. However, the registered person must ensure that all staff undertake update training in essential areas, such as first aid, fire safety, manual handling and food hygiene at the required intervals. An examination of three staff personnel records identified that one member of staff had significant gaps in their employment history; and verbal/ telephone references received for one member of staff had not been followed up in writing. Criminal Records Bureau (CRB) checks had been obtained for all staff. Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 41 and 42 The proprietor/ registered manager is a qualified and experienced person. However, she must ensure that the residents’ best interests are safeguarded by the home’s record keeping. EVIDENCE: A wide range of records were looked at, including fire safety, recording of water temperatures, portable appliance testing and accidents/ incidents. The following issues were discussed with the registered person: • The registered provider must arrange for water heating and temperature checks to be undertaken for compliance with Legionella and to ensure that the services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. During the visit the registered person made arrangements for this to be actioned the following day. Water temperatures are being checked and recorded. However, the registered person must ensure that all hot water outlets in both houses DS0000027882.V281186.R01.S.doc Version 5.1 Page 19 • Bethel Care Home are regularly checked and adjusted to ensure safe water temperatures are being maintained. Work on the installation of a fire protection/ alarm system has now been completed. Bethel Care Home DS0000027882.V281186.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 Adults 18-65 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 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X X X 2 2 X Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES 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 YA23YA35 Regulation 13 Requirement The registered person must ensure that all staff receive training in adult protection/ abuse awareness. (Timescale of 31/05/05 and 31/10/05 not met) The registered person must produce a planned maintenance and renewal programme for the fabric and decoration of both houses. A written copy of the programme must be provided to the Commission, which must include timescales and areas highlighted for priority action. The registered person must make suitable arrangements for checks to be undertaken for compliance with Legionella and to ensure that the services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. A copy of the test certificate must be sent to the Commission. The duty rota must record the actual hours worked by staff each day. The registered person must operate a robust recruitment procedure and ensure that all DS0000027882.V281186.R01.S.doc Timescale for action 31/03/06 2. YA24YA27 23 31/03/06 3. YA30 16 31/03/06 4. 5. YA33 YA34 17 19 02/02/06 02/02/06 Bethel Care Home Version 5.1 Page 22 6. YA41YA42 13,17 & 23 verbal/ telephone references received for staff must be followed up in writing. All gaps in employment history must be explored and reasons recorded. The temperature of all hot water outlets in both houses must be regularly checked and adjusted accordingly to ensure safe water temperatures are being maintained. 02/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bethel Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Care Home DS0000027882.V281186.R01.S.doc Version 5.1 Page 24 - 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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