Inspection on 14/06/05 for Bethesda

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bethesda 03/10/07

Bethesda 04/01/07

Bethesda 22/11/05

Bethesda 09/11/04

Bethesda 01/06/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Bethesda 25 Croft Road Torquay Devon TQ2 5UD Lead Inspector Stella Lindsay Announced 14 June 2005 th 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. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bethesda Address 25 Croft Road, Torquay, Devon TQ2 5UD 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) 01803 292466 01803 294205 lesleycraddock@cch-uk.com Bethany Guild Christadelphian Homes Mrs Lesley Craddock Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23), Physical disability over 65 years of age of places (23) Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2004 Brief Description of the Service: Bethesda provides residential care for older people who may have physical disabilities. Bethesda is one of a group of Homes run by the Bethany Guild until this Trust was wound up and its assets transferred to Christadelphian Care Homes on 1st July 2003. There are 23 registered places at Bethesda, 19 in single rooms, plus two double rooms. All have en suite wc and hand basin, and all but five have an en suite shower or bath. A shaft lift gives access to all four floors, and there is a stair lift to the mezzanine floor.Bethesda has a pleasant garden and is close to Torquay sea front and town centre. The aim of the Home is to ‘provide care and support in warm friendly surroundings where residents…can enjoy the company of those who share their faith, hope and values.’ Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Announced Inspection which took place between 9.30am and 5.45pm on a Tuesday in June 2005. It included a partial tour of the premises, examination of care records and staff files. As well as discussion with the Manager, the inspector met with 14 residents, one visiting relative, and four members of staff, and thanks all for their time. In addition, comment cards were sent to the Commission for Social Care Inspection by five residents and five relatives or visitors. All comments were positive, and will be represented in the text. What the service does well: What has improved since the last inspection? A new lift has been installed, to improve the reliability. Two rooms have been refurbished, with en suite facilities, including an accessible shower. Work has been done to improve accessibility around the lower ground floor, including lighting by a ramped floor, and a rail on the stairs. A carpet was being laid there on the day of the inspection. The Welfare Committee have continued with their visits to residents, and due to their efforts Residents’ questionnaires recorded an increase in security that Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 6 they had someone to confide in. Residents stated clearly during this inspection that they feel they are kept informed by management, and can influence decision-making within the home. 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. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 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 Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 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) 1,2,3,4,5 Full information is provided to prospective residents, and their care needs are carefully considered before accommodation is offered. EVIDENCE: Bethesda have a Statement of Purpose which has been up-dated to maintain accuracy. It is displayed in the entrance hall, with the Service Users’ Guide and the most recent inspection report. A recently admitted resident had this information in their room. Christadelphian Care Homes (CCH) have produced a format to be used for assessing a person’s care needs prior to offering accommodation, which covers all the required aspects of care, and a letter of confirmation is sent from head office. The Manager had met the recently admitted residents, and conducted an assessment of whether their needs could be met at Bethesda. Where health professionals had been involved, their information had also been considered. Recently admitted residents had been to stay before making their decision to move in. One had previously come as a volunteer to help with outings, and another said they had been visiting for over 20 years. All admissions are on Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 9 the understanding of a months trial. If re-assessment after one month confirms the suitability of the placement, the CCH ‘Agreement for the provision of residential care’ is issued. This clarifies the terms of residency, fees, method of payment, the accommodation to be offered, insurance cover, health and safety arrangements, and the complaints procedure. These were seen to have been signed by the resident and the manager. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 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) 7,8,10 Staff provide good care where it is needed, while promoting the independence of residents. The health needs of residents are met, with effective collaboration with health professionals. EVIDENCE: All residents have a care plan, and records kept of health care. For those who need assistance with personal care, a list of care tasks needed is produced, and initialled daily by the staff undertaking the care. There were records of staff and managers accompanying residents to appointments and health specialists, including sight and hearing specialists. Bethesda is involved in the Torbay PCT Falls Collaborative. After a staff member attended a course on preventing falls, it was decided that she would lead an exercise group. Residents’ initial doubts were overcome, and now a dozen attend regularly twice a week, to help maintain mobility. Residents are enabled to continue looking after their own medicines, if they are assessed as being safe to do this. Consent forms, assessments and dispensing requirements, signed by the resident were seen on files. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 11 Residents confirmed that their privacy is very much respected by staff in the home. Peoples’ wishes about their treatment during their final illness and arrangements after death had been recorded. One resident spoke of being helped through a recent bereavement by staff. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 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) 12,14,15 The residents’ lives are sustained and enriched by the spiritual and social life of the home. Residents are involved in decision-making within the home. The choice and quality of the meals is excellent. EVIDENCE: Residents have regular laundry and room cleaning days which suit them. Assisted baths are offered at regular times, but those who are able can shower in their rooms when they wish. Members of the wider Christadelphian community contribute to activities inhouse, with slide shows and music appreciation. A new TV which will play DVDs has been bought for the Sun Lounge. Trips out are arranged in the Home’s minibus – recently to the Passage House Inn and to Endsleigh Garden Centre. One resident said – ‘it’s amazing how the time goes’. Many have their own preferred routines. Some like to go into the garden in the mornings, several go for daily walks. Several study and write, and one is a potter. Bible readings are held every evening except Thursday and Sunday, when all who are well enough go to their Ecclesia. One resident said they think that peoples’ horizons close in as they grow older, but that living at Bethesda helps, with the outings and bible readings. Another said that with the ‘lovely meetings and discussions, one doesn’t begin to rot up Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 13 here’ – pointing to their head. Residents had decided that the Sun Lounge should be a non-food area when it was brand new, but now have changed that decision and agreed that they can entertain guests there, with refreshments. One resident said that if they had ideas about things to do, management would back them up, and another said that management keep them informed of what is going on. Menu requests are taken daily, and residents can request groceries to be delivered to their rooms. Lunch is a social occasion, and staff plan the seating arrangements with care. On the day of the inspection there was soup followed by three attractive hot alternatives, or salad. Vegetables and sauces were placed on the tables so that people could help themselves. Staff made efforts to ensure that everybody was suited. At tea-time, only five residents had come to the dining room. They all had ‘what they wanted’, and each had something different. The other residents were either out or had chosen to eat in their room. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 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 Bethesda has a satisfactory complaints procedure, and ample evidence that residents feel their views are listened to and acted upon. EVIDENCE: Bethesda has a Complaints procedure which is comprehensive and fulfils the requirements of this Standard. A hard backed book is kept to record complaints and untoward incidents. Any notes of a personal nature are kept in Service Users’ files. Residents were keen to stress to the inspector that they sincerely did not have complaints, but felt very fortunate. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 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) 19,20,22,25,26 The standard of décor at Bethesda is very good, and the garden is well cared for, giving the residents an attractive and comfortable home. The management have improved facilities and accessibility, and have plans for further improvement. EVIDENCE: Bethesda is a large detached house, with garages and a parking area, close to Torquay sea front and town centre. The garden is beautifully kept, with paths planned for accessibility. This organisation has shown commitment to meeting standards as quickly as possible, in the interests of providing as good a service as possible. Staff are expected to write anything they notice with regard to Health and Safety on a whiteboard displayed near the dining room. An assessment of the premises has been carried out by an Occupational Therapist. The conclusion was that Bethesda meets the needs of its residents. Recommendations to improve accessibility were made, and some have been carried out. The Manager has more radical plans which will greatly enhance the accessibility of the front entrance, and the bathing facilities. Plans are in Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 16 place to improve access to the dining room. It would be advisable to seek advice from an Occupational Therapist while still in the planning stage of the alterations. A shaft lift gives access to all four floors, and there is a stair lift to the mezzanine floor. A new lift has been installed, but a new door and seat for it are awaited. The main lounge is a large room with a bay window looking on to the garden. Each easy chair has a footstool. The loop system which had been installed in the lounge had worked satisfactorily, but now that residents with impaired hearing are using digital hearing aids, they are finding that the background noise is intolerable. Advice has been taken from the RNID, and different systems will be tried until an effective system is in place. The residents were enjoying their bright Sun Lounge, now two years old. The dining room floor has imperfections in its surface, and is due to be redesigned. There is non-slip flooring in bathrooms and toilets, including en suite facilities, and in the kitchenette areas of Service Users’ rooms. Grab rails have been fitted for those Service Users who need them, and raised toilet seats, walking aids and shower seats have been provided. An Oxford Minilift mobile hoist is available, for use during short illnesses, and an elk lift to help people up when they have fallen. A call bell system is installed in every room, including the lounges. It contacts the staff via pagers, which they carry. A printout of calls and answer times is kept. Pendant call bells are available for those at particular risk of falling. The laundry was seen to be well organised, with systems in place to avoid cross contamination. The ceiling of the drying room should be readily cleanable. The house was clean and sweet smelling throughout. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 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) 27,28,29,30 Staff who have a good understanding of the residents’ care needs are provided in sufficient numbers to meet those needs. There is a sound system of recruitment, to protect residents. Staff’s competence is maintained and enhanced by the provision of training. EVIDENCE: A rota is kept, showing who is on duty and in what capacity. There is a Senior Carer on duty from 8am until 9pm, and on-call at night unless the Registered Manager is sleeping in. There are two other care staff on duty 24 hours per day. This is in accordance with previous agreements, and is seen to be meeting the needs of the Service Users. CCH allow for extra staff to be engaged for special needs. Agency staff have been engaged when needed. A Cook, a Kitchen Assistant, and two morning cleaners on weekdays are in addition to the care staff. 13 of the 18 care staff have achieved NVQ2 or equivalent. There is a core of dedicated and committed care staff, but also many changes since the last inspection. The files of three recently appointed staff were examined. It was seen that references had been taken up, proof of identity obtained, and CRB clearances applied for, in order to protect residents. Interviews are recorded, and this includes a record of documents seen, including those required for immigration purposes where necessary. New staff have been engaged in a substantial induction training programme before moving on to their NVQs. Fire training had been provided, with charts showing that all Night care Staff had up-dates in November, March and June. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 18 Fire training had been booked again for 20/07/05, to ensure that staff would be kept up to date. Other training provided this year had included Moving and Handling, First Aid, Falls Awareness, Control of Infection, Dealing with Medication, Abuse Awareness and Food Hygiene. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 19 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) 31,32,33,35,36 The new Manager is working well and conscientiously to meet the needs of the residents effectively. Procedures are in place to monitor the quality of the service comprehensively, and management is responsive to staff and residents. The system of supervision needs to be implemented fully. EVIDENCE: Mrs Lesley Craddock has been appointed as Manager of Bethesda, replacing the former managers who have retired. Mrs Craddock qualified as a State Registered Nurse in 1966. Since then she has undertaken training courses, including Advanced Certificate in Counselling (Nottingham University) 1996, ENB Teaching and Assessing in the Workplace - 1996, and in June 2004 completed the Higher National Certificate in Managing Health and Care Services at Birmingham College of Food, Tourism and Creative Studies. She is working effectively to maintain and improve on the excellent service provided at Bethesda. Staff and residents said they felt that any suggestions they make are Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 20 considered. One fairly new member of staff said that they were impressed by the response. They had made a simple suggestion for a piece of equipment for a resident’s kitchenette, and next time they came on duty it was in place. Another had mentioned that some trays were heavy, and the manager provided trolleys. When staff reported that a resident’s disabilities had increased, their bedroom furniture was altered to enable staff to provide care safely. A member of the local Committee visits monthly to inspect the premises, the conduct of the home, and speak with residents and staff, and the Assistant General Manager of CCH makes three monthly inspections which look at all the standards and documents required by the regulations. Visitors’ questionnaires were available by the front entrance. A report is published, giving the results of the residents’ questionnaires. 100 satisfaction was recorded with regard to catering and contact with families. Personal Contacts (someone to confide in) had increased from 60 to 80 , due to the Welfare Committee’s efforts to encourage Residents to talk to one of them, or a Church Member. Welfare Committee members visit residents regularly, and report any concerns to the two-monthly meetings. Three residents meetings had been held so far during 2005, in January, March and May. Topics discussed included the need to maintain each others’ confidentiality within the home, as well as activities, outings and menus. A system of individual supervision and appraisal has been put in place, but still needs to be implemented to provide care staff with six sessions per year in order to give them feedback on their performance, ensure that changes in policy and procedure are shared, and that staff training needs are documented and followed up. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 21 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 4 3 3 4 4 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 4 15 4 COMPLAINTS AND PROTECTION 3 3 x 3 x x 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 4 3 x 3 2 x x Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 22 no 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. 2. Refer to Standard 26 36 Good Practice Recommendations The entire laundry area should be readily cleanable. The system of supervision and appraisal should be fully implemented. Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Bethesda D54-D07 S18327 Bethesda V222410 140605 Stage 4.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!