Inspection on 22/11/05 for Bethesda

This inspection was carried out on 22nd November 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

Bethesda 03/10/07

Bethesda 04/01/07

Bethesda 14/06/05

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 Unannounced Inspection 22nd November 2005 10:00 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 Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 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. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bethesda Address 25 Croft Road Torquay Devon TQ2 5UD 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) 01803 292466 01803 294205 Bethany Guild Christadelphian Homes Mrs Lesley Gillian 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 DS0000018327.V251421.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 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 DS0000018327.V251421.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a Tuesday in November 2005, between 10.30 and 5pm. It involved a partial tour of the building, and examination of health and safety records and the medication system. As well as discussion with the Registered Manager, the inspector met with fourteen residents, two staff, one visiting relative, and thanks all for their time. The Commission for Social Care Inspection has introduced key standards to be inspected over each inspection year. Therefore, unless it is felt necessary by the inspector, some standards will not be inspected. To obtain a full picture of the home please refer to the report of the Announced Inspection which took place on 14th June 2005, when most of the core standards were inspected. What the service does well: What has improved since the last inspection? Residents’ interest in the garden had continued, and they were pleased with their new bird table, and a statue that had been donated. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 Page 6 A Data Projector and lap-top had just been obtained, for the showing of videos and DVDs as well as television programmes on the clear wall at the end of the Sun Lounge. The Manager has started displaying a printed list of activities for each month. The lift had been in the process of being repaired, and after setbacks was at last working satisfactorily. 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 DS0000018327.V251421.R01.S.doc Version 5.0 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 Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 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): These standards were not assessed. EVIDENCE: Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 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): 8,9 Staff provide good care where it is needed, while promoting the independence of residents. The health and medication needs of residents are met, with effective collaboration with health professionals. EVIDENCE: A resident whose health care and mobility needs have increased had been moved to a ground floor bedroom so that they could continue to be involved with the life of the home. This person said, ‘it’s very, very pleasant here’, in spite of their many problems. There is a policy on the safe use of bed rails, and a risk assessment was completed before they were brought into use. The District Nurse had been consulted. There was evidence of residents having been treated by Occupational Therapists, of advice from the Sensory team, and equipment obtained to help people with sight and hearing loss. A Senior Carer leads an exercise session every Monday and Thursday morning, with residents finding this beneficial. Residents are enabled to administer their own medication if they are assessed as capable of doing this safely, and fridges are provided in bedrooms where Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 Page 10 necessary to chill medication. All residents have lockable storage in their rooms. A resident who needs advice from the Diabetic Nurse contacts her directly. The home has a policy and procedure for the administration of medication, and makes this available to staff. A list is kept of the staff who have been trained and are judged to be competent to administer medication. The records were seen to be properly kept, and the Senior Carer was seen during the inspection to be administering medication with care. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 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): 12,13,15 The residents’ lives are sustained and enriched by the spiritual and social life of the home. Good support is provided by the Welfare Committee as well as friends and relations. The choice and quality of the meals is excellent. EVIDENCE: Residents talked about their life within a religious community. The daily Bible readings and twice weekly visits to their Ecclesia are central to their lives. They have often known each other for many years before moving into Bethesda, and are well known to each others’ visitors. As well as sharing a spiritual life, some said that their shared attitude towards such attributes as tolerance and forgiveness were an important contribution to a successful shared life. However, they also said they felt free to come and go. Some residents go for daily walks. Two were going out together as the inspector arrived, and another said they walk to the pier every day. The Manager has started displaying a printed list of activities for each month. A Data Projector and lap-top had just been obtained, for the showing of videos and DVDs as well as television programmes on the clear wall at the end of the Sun Lounge. Coffee mornings have continued on the first Tuesday of each month, with visitors welcomed, mostly from local Ecclesias. Outings are Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 Page 12 arranged on the fourth Tuesday of each month. Recent destinations have been Badgers Holt, a minibus tour to see the Tall Ships, followed by a cream tea at Cockington, and a fish and chip lunch. Communal teas are held in the dining room on Bank Holidays, and sherry and cake are enjoyed on residents’ birthdays, after the evening Bible readings. The Bible readings are often lead by residents of Bethesda, but visitors from the Ecclesia lead them once or twice a week, and join in a hymn singing session on Thursday afternoons. The Welfare Committee help with visiting residents and escorting people on outings, as well as on-going fundraising for extra amenities for the home. Residents can receive visitors in their own room, or in the lounge or sun lounge. The policy on visiting is included in the statement of terms given to each new resident. There is a ‘garden flat’ where visitors to the home can stay, by arrangement, as long as they do not need care to be provided. They are invited to join the residents for meals. Staff see residents each day to take their menu requests, and residents can request groceries to be delivered to their rooms. Lunch is a social occasion. Staff plan the seating arrangements with care, to give residents variety in their company. A choice of main dishes is offered, and individual requirements extra to these were seen to be provided. The sweet trolley was brought round, so that residents could choose their combination of fruit, pudding, custard or cream. Most residents have tea in their room, at a time to suit themselves, except on special occasions. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 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): 18 Residents are protected from abuse by the systems of support that are in place. EVIDENCE: CCH has a policy on abuse which was updated in June 2005, and includes the requirement for staff at Bethesda to be aware of the Alerters’ Guidance issued by Torbay Council. All staff at Bethesda had seen the ‘No Secrets’ video, and some had received training on recognising and dealing with abuse in July 2005. The Staff Handbook includes policies on harassment and Whistle blowing. Members of the Welfare Committee visit regularly. Residents have told the inspector that they would be able to tell the Manager or Senior Carer if they had any worries, and that they would prefer to speak to a member of the Welfare Committee than have an advocate from outside the Christadelphian community. A visiting relative said, ‘We don’t have to worry about Mum’, because they had confidence in all the Senior staff to protect her interests and provide good care. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 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): 19,22,24,25,26 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. The residents take a great interest in the garden, and were pleased to tell the inspector about a statue which had been donated. A bird table had been obtained, and construction was completed by a resident on the day of the inspection. Security of garden equipment had been improved, following a burglary from a shed. During the inspection a vacant bedroom was being redecorated in preparation for a new resident. A carpet was also due to be laid in this room, and one other. Accessibility around the lower ground floor had recently been improved, with new carpet, lighting beside a slope, and new steps up to the terrace. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 Page 15 An external lift had been installed to take people directly from the Sun Lounge to the patio, and was awaiting safety rails to become operational. A bedroom had been taken out of use, in order to provide improved bathing facilities. The Manager is persevering with efforts to help residents with hearing loss to hear the Bible readings in the lounge. No effort is being spared to make the loop system function usefully, and a hearing aid specialist from Western Power was due the day following this inspection to examine it, and repair the pick-up. All residents seen were pleased with their bedrooms. They have varying outlooks, and some have a fridge, microwave, and kettle, according to risk assessment, and preference. There were a variety of central and wall light fittings, and plenty of electricity sockets. All had lockable storage. It was not possible to control the temperature in one room because of hot pipes running inside the walls. It was not a problem at the time, because of the season. Good laundry procedures are in placed. Residents confirmed that their clothes are well cared for, and a system is available for keeping soiled items separate. The laundry is in good order, but the drying room would benefit from having smooth cleanable walls and ceiling. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 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): These standards were not assessed. EVIDENCE: Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31,36,38 The management team is working well and conscientiously to meet the needs of the residents effectively. EVIDENCE: Mrs Lesley Craddock has completed her registration as Manager of Bethesda. She 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. CCH are looking ahead and planning the development of their management team. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 Page 18 The Manager has carried out supervision sessions with individual staff, and is preparing Senior Carers to take responsibility for supervising other care staff. Staff were up to date with Fire Safety training. Night care staff had completed questionnaires as an extra update. The fire precaution system was serviced professionally on 6/7th June 2005. Moving and Handling training had been provided, with one care assistant and one domestic still to undergo this. Accidents were reported and recorded. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 4 X X 3 X 4 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X X X 3 X X Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 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. 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 OP25 OP26 Good Practice Recommendations The wall should be insulated where hot pipes run past a bedroom. The entire laundry area should be readily cleanable. Bethesda DS0000018327.V251421.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Ashburton Office 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 DS0000018327.V251421.R01.S.doc Version 5.0 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. 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!