Inspection on 03/10/07 for Bethesda

This inspection was carried out on 3rd October 2007.

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 04/01/07

Bethesda 22/11/05

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 Key Inspection (unannounced) 3rd October 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 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.V345895.R01.S.doc Version 5.2 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 www.cch-uk.com Christadelphian Care 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.V345895.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2007 Brief Description of the Service: Bethesda provides residential care for up to 23 older people who may have physical disabilities. Bethesda is one of a group of homes run by Christadelphian Care Homes, a registered charity. Bedrooms are all attractively furnished and decorated, some with fine views. Every room has en suite toilet facilities, one has its own bath and four have accessible showers. There are three bathrooms with assisted bathing facilities and two showers for assisted or independent use. A shaft lift gives access to all four floors, and a second lift gives access to the mezzanine floor. Easy access has been provided throughout the premises, with a lift from the sun lounge to the lawn. Bethesda has a pleasant garden and is close to Torquay sea front and town centre. The aim of the Home is to ‘provide loving individual care enabling people to lead fulfilling lives within a spiritual environment centred on the Christadelphian ethos.’ Current fees range from £400 to £520. Fees vary according to care needs. £50 extra is charged for a single person occupying a double room, or there is a discount if a couple are sharing. The most recent inspection report is on display in the entrance hall, along with Bethesda’s Statement of Purpose and Residents’ Handbook. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days in October 2007. It involved a tour of the premises, and discussion with twelve residents, seven staff on duty, the Registered Manager, and examination of care records, staff files, health and safety records, and the medication system. The Registered Manager provided useful information about the running of the home prior to this inspection. Staff and residents’ relatives returned surveys and comment cards to the Commission for Social Care Inspection, and their views are included in the text. What the service does well: What has improved since the last inspection? A major building project has been completed, introducing new and improved facilities, and making the whole house accessible to all. In particular, the floor of the dining room has been raised to remove three steps. This is a huge benefit to residents every day, making it so much safer and easier for them to Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 6 get to the dining room, and not having to wait for assistance. The kitchen has been entirely refurbished, with the installation of new equipment and a chill room. Trolleys are now provided for staff to serve meals. The house was repainted externally, and the roof replaced. A new passenger lift was installed, giving easy access to the mezzanine floor. There was already a shaft lift to the four main floors. Access to the garden is either via the front door and through a side gate, or via the Sun Lounge, and down a outdoor lift. The level of the porch floor has been raised and a slope to the front door built, to provide level access. The drive in access and parking area have been improved, and a non slip surface has been provided for pedestrians. Other improvements include the promotion of Person Centred care and the development of the key worker role for care staff, to focus on residents rather than the task. A weekly written menu has been introduced, at the suggestion of residents, so that they can order their choices in advance, while still being able to change their minds nearer the time. New arrangements for the storage of medicines have been introduced, to promote safety and the privacy and dignity of residents, by keeping them in their private accommodation. 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. The summary of this inspection report can be made available in other formats on request. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 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.V345895.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good. Residents were well informed about the service, familiar with the home and able to make a positive choice. Staff did not always receive the information they need to prepare for the new admission. This judgement has been made using available evidence including a visit to this service. Intermediate care is not offered at Bethesda. EVIDENCE: Bethesda has a Handbook, containing interesting and useful information about the home and the service provided, which has been updated again, to include the new building arrangements. Residents had been asked for contributions of ideas, and quotations are included with their advice for people thinking of moving in. The Handbook and the Home’s Statement of Purpose are produced in large print for those with visual impairment. A DVD has been produced, showing the work of the Christadelphian Care Homes across the country, with many contributions from residents as well as staff and management. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 9 Prospective residents are often already familiar with Bethesda, having visited for coffee mornings, The trial period has been increased to 8 weeks, to make sure the person is suited by the life of the community before offering a long stay place. The prospective resident or their representative fills in the initial assessment form, and a GP report is requested (with their agreement). The Manager meets with them in their own home, to carry out a full assessment. Christadelphian Care Home (CCH) managers in different parts of the country do assessments on each others’ behalf due to distances involved. All aspects of care are considered, including social requirements, and risk assessments are considered. When the decision is made that the person’s needs can be met, a letter of confirmation is sent, indicating the level of care required and the appropriate fee. A copy of such a letter was seen on file. The inspector met with two of the recently admitted residents. One had previously stayed at Bethesda for holidays. The other said it had taken them two years to make up their mind to come in. They said ‘the staff were very helpful – it’s a lovely home’. The Manager had printed out their contract in the font size of their choice for a new resident with visual impairment. Some staff who spoke with the inspector or replied to surveys said they did not always receive information about a resident in good time before they moved in, or did not receive enough holistic information. The Manager said that the information is put on the computer record, so the system of letting all staff know when to look it up should be reconsidered, as well as making time to discuss any preparations. The Manager is keen to introduce an admission satisfaction survey, so that the home will be able to respond to any issues raised. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is excellent. Health and personal care needs are assessed and met with care and consultation, accurate recording, and attention to the privacy and dignity of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Care plans of two residents were examined. Contact details are recorded in easily accessible form. A front sheet with photo, interests and profile to accompany a resident to hospital are always kept updated in case of emergency. Each care plan has a summary to enable new staff to quickly understand care needs. As many separate plans for meeting different aspects of care needs are added, as necessary. One computerised file examined had eleven separate plans, covering different issues including medical needs. The other had nine. These had been drawn up by the key worker together with the residents. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 11 A task sheet is produced on behalf of each resident, with precise care needs listed for morning, afternoon and night. Care staff initial each task as they are accomplished, so they are accountable for their work. This home is successful in offering care flexibly, according to peoples’ changing needs. One resident told the inspector how they like to ‘do things for myself’, but occasionally has a day when she cannot do anything, and ‘then they help me all they can’. This person liked to use the new bath with assistance once a week, but also used their own en-suite shower in between. A survey has been recorded of each resident’s hearing problems. The Manager is keen to enable all members of the community to hear each other when they sit in the large lounge for daily bible readings. This is a most important element of the spiritual life of the community, and she is trying to ensure that all may participate fully. She was due to take a resident to their audiology appointment shortly after this inspection. The Manager is introducing and promoting the role of Key workers. She is producing a display for each resident’s room to let them know who their key worker is. She has produced a format for recording residents’ life histories, if they wish to do this. She said that she will encourage care staff to spend quality time with their key residents, to allow individual attention, which could include the compilation of life stories. The home has a policy and procedure for the safe handling of medicines, and staff were seen to be administering medication with great care. Residents are enabled to look after their own medication as long as they are able, and assessments are recorded with respect to continuing ability. A new system of storage has been introduced, which encourages self-medication where suitable. A safe storage unit has been fixed in an appropriate place in each resident’s private accommodation. If they need to have their medication administered by staff, the Senior in charge comes to their room at the necessary time, administers the medication and completes the record in the privacy of their room. This also makes it impossible for staff to give tablets to the wrong person. Records were checked and found to be accurate. There is a reliable method of recording changes in dosage made by the doctor. A copy is kept of every prescription requested outside the normal monthly supply. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This community has a rich spiritual life and continuing support from Christadelphians across the region. Sufficient staff attention needs to be consistently available for informal social activities for the more dependent residents. The choice and variety of food provided is very good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff try at all times to be flexible and order the day to meet the varying needs of residents. During this inspection, one resident was going out for lunch with a relative, so staff ensured that their hairdressing appointment was early, so that they would be ready to go. The hairdresser visits every Wednesday, and the chiropodist every few weeks. On the first Tuesday of each month the Welfare Committee hold a coffee morning in the lounge. They also arrange a very popular monthly outing, and come along to help. They have gone with residents for coffee at garden centres, and cream teas, and the October outing was to be Powderham Castle. Staff were concerned that recently there was not always time to take less mobile residents to the garden, and that they had not been able to maintain Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 13 the exercise group that had been enjoyed. There had previously been an Activities Record book, but it was not seen at this inspection. The Manager said that she will keep it in the lounge, for all to see, and will encourage the continuation of the exercise group, as long as residents wish. Several of the more mobile residents told the inspector that they go out for walks, alone or with another resident, and others said they had enjoyed the garden. One said that they like to help people, and they go to the shops on errands for those less mobile. Some enjoy sitting or playing games in the Sun Lounge. One resident was enjoying Ma Jong on the computer during the afternoon. Residents are looking forward to the delivery of a piano. One resident had had great trouble getting their phone line working, which was most important for their contact with family members. They were pleased to tell me how staff had made the time to help get this problem sorted out. After tea all residents join together for bible readings unless they are ill, and there are often visitors sharing the readings. The Manager is a member of the community and joins in the Bible Readings. On Sunday afternoons once a month, a small service is held in the Sun Lounge for residents who are unable to attend the Ecclesia. Transport is arranged at a small charge for all who wish to go to the Ecclesia on Thursday evenings and Sunday morning and evening. Each month the programme of events and activities is printed and displayed throughout the house. This showed the bible readings and other meetings that were planned, as well as visitors expected from the wider community, a slide show and a visitor with a PAT dog (Pets as Therapy). Fresh fruit is freely available, and each lunchtime there is a choice of main meal, and alternative of salad and omelette available. A request form has been produced showing the choices on the menu for the main meal. Residents can order up to two weeks in advance, while still being able to change their minds nearer the time. Residents knew what they would be offered for lunch that day, and that there is always an alternative. Staff see each resident every day and offer choices for tea. Residents may have a microwave cooker, fridge, kettle and toaster in their room subject to risk assessment. One resident said their microwave ‘is good for porridge and cheese on toast’, and they sometimes cook a piece of fish. They have little books to put in weekly orders for provisions for their rooms. At lunch, there were posies of flowers from the garden on each dining table. A resident went round offering extra water from a jug. On the day of this inspection the roast lamb was chosen by all but one. Carrots and Brussels sprouts were put on the table in small tureens, boiled and roast potatoes were brought round, followed by gravy and mint sauce. There is always a choice of vegetables, and two sorts of potatoes. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 14 People could choose any combination from the pudding trolley. There were a light and crunchy apricot crumble, mandarin oranges, custard and cream. Seconds were offered. Residents said they had enjoyed their food, and very little was returned to the kitchen. Lunch is a sociable occasion, and staff arrange the seating daily, to give people a variety of company. The Manager shares the meal. After lunch, the Senior Carer gave notices, including who would lead the bible readings that evening, which staff were coming on duty, and the purpose of my visit. The cook had discussed menu choices with residents. He had found that some like curries and Chinese stir-fries. The inspector saw the record kept of what individuals have eaten each day. The suggestion for cherry tomatoes had come from a residents’ meeting, and have been added to the order. Residents have become accustomed to commercial cakes and biscuits, but the cook is being encouraged to provide home made cakes, to promote homely baking smells through the house and enhance choices for residents. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. Residents are protected by good policies and procedures and general good practice by staff and management of listening to residents’ views. This judgement has been made using available evidence including a visit to this service. 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, though no complaints had been recorded. Any notes of a personal nature would be kept in residents’ files. There had been no formal complaints since the last inspection, and no disciplinary action had been needed. The Complaints file is reviewed by the Trustee and the General Manager in their regular visits to the home. Both the recently admitted residents knew about the complaints procedure. One had seen it in the home’s Handbook that they had in their room. The other said they would speak to management if they had any issues to raise, they felt quite capable of ‘speaking openly if necessary’. Residents have told the inspector that if they had any concerns they would prefer to talk to a relative or one of the Christadelphian Community, rather than an independent advocate. Lifelong members of the community have a loyalty to each other, which is a great strength and comfort to many, but places a responsibility on management to ensure that people are enabled to mention any unhappiness. Members of the Welfare Committee have befriended some of the more dependent residents, which gives them another opportunity for their voice to be heard. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 16 Staff had received training in the protection of vulnerable adults, and are provided with this training annually, to maintain their awareness. It had been arranged during the month following this inspection. CCH has a policy on abuse which includes the requirement for staff at Bethesda to be aware of the Alerters’ Guidance issued by Torbay Council. Bethesda has a suitable Whistle Blowing policy, protecting staff who bring to light any problems, whether further investigation shows them to be wrong or right, as long as they were not making false and malicious allegations. Not all staff were aware of this policy, in spite of it being included in the staff handbook. The Manager should take steps to ensure that everyone is confident in their knowledge about their rights and responsibilities. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,26 Quality in this outcome area is excellent. Bethesda is an attractive and comfortable house, with safety measures in place, and access for people with disabilities to all parts of the house and garden, promoting independence. It is well maintained and clean throughout. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A major project has been completed over the past year. The house has been made accessible throughout, and improved facilities have been provided, as well as repair work found to be necessary in the process. The house was repainted externally, and the roof replaced. A new passenger lift was installed, giving easy access to the mezzanine floor. There was already a shaft lift to the four main floors. Access to the garden is either via the front door and throuhgh a side gate, or via the Sun Lounge, and down a outdoor lift. The level of the porch floor has been raised and a slope to the front door built, Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 18 to provide level access. The drive in access and parking area have been improved, and a non slip surface has been provided for pedestrians. The level of the dining room and kitchen floors have been raised to remove three steps. This is a huge benefit to residents every day, making it so much safer and easier for them to get to the dining room, and not having to wait for assistance. The kitchen has been entirely refurbished, with the installation of new equipment and a chill room. Trolleys are now provided for staff to serve meals. The lounge is large and elegant. The Manager is persevering in her efforts to enable residents with hearing impairments hear each other when they are holding their bible readings. One of the bathrooms has been upgraded, and another has been provided in what was formerly a resident’s bedroom. This one contains a high level toilet, shower, Malibu bath and basin. It is a most attractive and popular bathroom, and staff and residents described it as ‘lovely’. It should not be used to store mobility equipment. A new accessible cloakroom had been provided for the convenience of residents. Two new bedrooms had been provided, in a part of the building that was formerly staff quarters. The rooms are big enough to conveniently accommodate independent wheelchair users, and the new en suite showers had been installed as wet rooms, to promote independence. New rooms had attractive kitchen areas, with round sinks and drainers, some with wood panelling and shelves. People had microwave cookers, fridges, kettles, and toasters in their rooms, according to risk assessment. Rooms and areas involved in the alterations had been redecorated, and the house was looking bright throughout. The central heating system had been upgraded. There are call bells in each room, and residents at risk of falling have pendant alarms. Liquid soap and paper towels are provided where necessary. New communal hand basins with knee operated taps had been fitted, for improved hygienic hand washing. Laundry is dealt with in a separate part of the home, and good procedures are place to prevent any risk of cross contamination. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. Well-motivated, well-trained and caring staff are employed, who work together well to enable residents to maintain their quality of life. This judgement has been made using available evidence including a visit to this service. 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. Two other care staff are employed 24 hours per day, except for Sunday afternoons when there was only one carer and one Senior. This was causing anxiety to staff and residents, who felt that ‘unforeseen events’ could put them all at risk. The Manager said that it would be dealt with immediately. A Cook, a Kitchen Assistant, and two morning cleaners on weekdays are in addition to the care staff. This level of staffing is found to meet residents’ current needs, though staff were endeavouring during this inspection to fit in their normal duties while covering for the kitchen assistant. Residents were very complimentary towards their cleaning staff. 75 of the staff have the nationally recognised qualification known as National Vocational Qualification level 2 in Care, or are working towards it, and of these 20 have achieved level 3. This is very good achievement, maintaining a qualified workforce. A staff member said in a survey that, ‘I had good support when I did my NVQ’. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 20 The files of three recently recruited workers were examined. All had the documents required by the regulations and a Criminal Records Bureau clearance, to protect residents from potential harm. Written references had been requested, but were still awaited on behalf of one. Bethesda has an induction programme that is followed by all new staff. The Manager kept a chart showing the training achievements of the staff. The programme was continuing, with Fire Safety, Moving and Handling, Abuse Awareness and Care planning booked for the autumn. Staff had received training in care of people with dementia, care planning, person centred care, and bereavement and loss. All staff returning surveys considered that training provision was good to help them understand and meet the needs of residents and keep them up to date with good practice, and all had more than three days training during the year. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Good management systems are in place, to ensure continuation of a good quality service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Lesley Craddock is the Registered 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 keeps up to date her health and safety training along with all her staff. Her qualities as an organiser are appreciated by the residents - ‘Lesley is a great innovator’, said one, ‘always making improvements’. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 22 Good systems of support are in place, with supervision regularly provided, and staff meetings held. Senior staff meetings should be continued regularly, to promote good communication and appreciation of each other’s contribution. Work on improving communication between the whole staff team should be encouraged, to enable all to speak openly and share anxieties. Staff felt that support from CCH was very good - ‘I think the service is excellent, wages, conditions – if we ask for anything we get it’ was a comment in a survey returned to the CSCI. The home is visited monthly by the Trustee who speaks with residents and staff, checks the premises, complaints record, social events and other quality assurance checks. The General Manager is a frequent visitor, and carries out a full audit twice a year. A new and detailed quality audit questionnaire had been published to promote person centred care, and eight replies received from residents so far. The Quality Assurance Report for 2006 had been supplied to the CSCI, and the Manager undertook to supply the new one when it is complete. Cash is kept on behalf of some residents, with computerised records. A sample were checked and found to be correct. The Trustee checks these on his monthly visits. Residents are encouraged to handle their own finances, and given advice if necessary of how to obtain independent advice. Professional fire training is provided every six months. Moving and Handling training is provided annually, health and safety two-yearly, and food hygiene three yearly, as appropriate. Fire risk assessments are reviewed every six months, or more frequently if necessary, due to any changes. Two fire exit doors had been replaced, and the fire alarm system had been upgraded. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 23 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 4 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 4 X 4 X 4 STAFFING Standard No Score 27 2 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 24 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 OP27 Regulation 18(a) Requirement The Registered Person shall, having regards to the size of the care home … ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Sunday afternoons must be staffed sufficiently, to maintain care and safety of residents. Timescale for action 30/11/07 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 OP3 OP18 Good Practice Recommendations The Manager and staff should reconsider how they share information, with regard to preparing to admit a new resident. The Manager should ensure that all staff are confident in their knowledge of the home’s Whistle Blowing policy. Bethesda DS0000018327.V345895.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V345895.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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