CARE HOMES FOR OLDER PEOPLE
Bethesda Eventide Homes 59a Henley Road Ipswich Suffolk IP1 3SN Lead Inspector
Claire Hutton Unannounced 20 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Bethesda Eventide Homes Address 59a Henley Road, Ipswich, Suffolk, IP1 3SN 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) 01473 211431 01473 211431 none available Bethesda Eventide Homes Mrs Barbara Durrant Care Home 22 Category(ies) of Older People (22) registration, with number of places Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 22nd September 2004 Brief Description of the Service: Bethesda Eventide Homes is a care home providing personal care and accommodation to 22 older people. It is owned by the registered charity, ‘Bethesda Eventide Homes, Ipswich’ and is managed by trustees who are associated with Bethesda Baptist Church in Ipswich. The home is located in a residential area of Ipswich near to the town centre and other amenities, such as Christchurch Park, and is on a bus route. The building is a two storey converted domestic dwelling, with 21 bedrooms (referred to as homes by the management to make them more personal), which all have en-suite toilet and wash basin facilities. The home is registered for 22 people, so that should any resident be admitted who wished to share a bedroom they could be accommodated in one of the larger rooms, (none were sharing at the time of this inspection). Access to both floors is via a shaft lift and a stair lift. There are 2 assisted bathrooms and communal areas comprising dining room, lounge and a conservatory. The home has a wellmaintained garden that is accessible through the lounge and conservatory. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection carried out over 5 hours on a mid week afternoon and early evening. Three residents were spoken with in private. Three staff were spoken with, including the newly appointed manager for the service. A tour was made of the communal accommodation and two private bedrooms were seen with the residents permission. Records inspected included, care plans, daily statements, pre assessments, risk assessments, terms and conditions, roters, nine policy documents and some records relating to medication. What the service does well: What has improved since the last inspection?
Bethesda continues to offer a good quality service to the people who live there. The one requirement made at the last inspection had been actioned. Evidence of the nine policies and procedures noted in the last inspection report were available for inspection.
Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 6 The organisation that manages this home had successfully planned and managed the retirement of the existing registered manager and appointed a new manager that was registered before the existing manager left. This has made possible a smooth transition of management within the home and no loss of quality. Both managers were spoken with as it was the previous managers final week at the home at the time of this inspection. Staff spoken with felt very supported by both managers. 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 Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.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 Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.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) 2, 3 and 5 . 6 does not apply People who use this service can be assured the home has a clear admission procedure they follow and a proper assessment will be completed before admission, therefore they can expect their needs to be met. EVIDENCE: Evidence of terms and conditions of residence were seen in three residents files. These had been issued to the residents and signed and dated by the appropriate people on behalf of the home and the resident themselves. The pre admission assessment for three service users was seen in individuals files. These were said to have been completed before admission, but no date was on the documents. The manager sated that she visited people in their own home to gather the detailed information about their individual needs. Information on the pre admission assessment included: medical, medication, falls, personal safety, mobility, hearing, vision, chiropody, mental function, communication and speech, personal care needs, diet, social and emotional
Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 9 needs, interests and finances. This information was also supplemented with further information from relatives or a social worker if appropriate. One resident could recall the visit the manager made to them at home before they came to Bethesda and the visit to Bethesda. One further resident had moved to the home as respite to try it out before deciding to move in permanently. The statement of purpose for the home sets out the process for applying for a place at the home and the four week trial period available. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.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) 7,8,9 and 10 Health and personal care needs of residents are identified and met therefore; residents can be assured that any associated risks are kept to a minimum. EVIDENCE: Full detailed care plans for the three people tracked were available to care staff. They contained appropriate level of details in areas such as manual handling, risk assessments for pressure care and falls, continence assessment along with day and night time care required. The daily statement completed by care staff was factual and stated care given. As part of the admission checklist upon entry to the home each resident has documentation to show they are registered with a GP, chiropodist, dentist and optician. In the plan of care if a health care appointment had been made then the outcome was documented for staff to be aware of any changing health care need. One resident stated that if they needed to see the doctor they just asked and it was arranged promptly. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 11 The person at the home who was delegated the task of medication was met and the procedure at the home around medication was looked at. There was evidence that the home currently had a practice of secondary dispensing and that controlled drugs were not recorded in a bound book. It was agreed and decided that the best way forward was for the specialist pharmacy inspector, from the CSCI, to come back to the home in the coming weeks. He would conduct a full audit on medication and the processes involved and report back to the home on the best practices to be followed. The manager and staff concerned were supportive and positive about this approach. These outcomes will be documented in subsequent reports. Residents were seen to be treated with respect from staff and the privacy of individual rooms was upheld. Individual rooms were only seen with the consent of the respective resident. Staff spoken with demonstrated an understanding of respect and care needs of residents in line with individual care plans. Residents confirmed that they received their mail unopened and that they had their own telephone installed if they wished. All three residents spoken to in private confirmed that staff ensured their privacy and dignity at all times. More than one resident said the staff were excellent. Comments such as ‘polite, loving and caring’ were used. One resident felt that staff demonstrated their caring nature by ‘bringing me cocoa in the night when I cannot sleep’. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.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) 12,13 and 15 People who use this service can expect that the lifesytle and catering on offer will match their expectations and preferences and so will not be disappointed. EVIDENCE: Pre admission assessments and care plans contained documentation of preferred lifestyle in terms of religious and recreational interests. Staff spoken with knew individuals preferred lifestyles and were able to discuss choices made by residents and how they supported them. One resident spoken with was keen to maintain their three weekly attendance at a chosen club in Ipswich and only came to the home knowing that this would be possible. The resident explained how they got to the club and how they just let staff know when they’d gone and when they’d returned. Another resident spoke about their piece of garden that was maintained with the help of a relative. Also, the bird table positioned at the window that brought them much pleasure. Relatives can visit at any reasonable time. Residents confirmed that they had visitors when it suited. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 13 Residents at Bethesda choose this particular home for the integral input they receive from the local Baptist Church. More than one resident felt this was a positive aspect of their care that affected all aspects of their life at Bethesda. A service of devotion had been conducted at the home that morning. The home has several volunteers who work within the home in varying capacities. The home had an appropriate policy on working with volunteers. Moreover, they did not replace staff members. Bethesda has in the past received a 4 rating for catering which is standard exceeded/commendable. Current residents confirmed that the food at Bethesda remains a very good quality. The choice from the menu and portion size was said to be ‘very good’. One person joked ‘the only complaint is they give you too much food’. Residents particularly liked the ability to order tea and biscuits for their visitors and to ask at any time for a snack when the needed it or to take fruit from the bowl when they wanted to. Meals could be taken in the dining room or individuals rooms. Since the last inspection the home have developed a very detailed policy on Food Hygiene and Nutrition. In addition, the home now has a nutritional assessment tool to use with residents. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.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 People who use this service can be assured that their concerns will be taken seriously and action taken. EVIDENCE: The home have an appropriate complaint procedure that is available. (Displayed at the home and part of the Service User Guide) There were no recent complaints and none outstanding. Residents spoken with had no complaints and did not have any dissatisfaction with the service on offer. Any matters that the regulator have raised with the organisation have always been promptly attended to. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.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) 19,20,21,22,23,24,25and 26 People who use this service can expect to have a comfortable, safe and well maintained home that meets their needs. EVIDENCE: Bethesda continues to offer an environment that is appropriate and well maintained and meets all the above standards. An example of attention to detail is the downstairs communal bathroom. The room is large, warm and beautifully clean. The floor had a good quality non slip floor. A rubber bath mat for safety was provided. The bath water temperature was recorded at 44ºc. The bath was a good quality assisted bath, suitable for older people. The toilet had appropriately positioned handrails on either side and other hand rails were around the room to aid residents mobility and stability. The door had a lock and a notice to turn when in use. The bathroom met the needs of people who live at Bethesda. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 16 A resident and the inspector used the shaft lift as they went to their individual room. The shaft lift was modern and a smooth ride. Two individual bedrooms were seen. These were both well decorated and furnished. Like all areas of the home these were clean and fresh in appearance. The rooms were individualised and had personal possessions and furniture in them. They met the needs of the individual. One resident was very proud of the ornaments and plants they had. Every bedroom has its own en-suite. The communal areas were homely in appearance and the chairs were comfortable for the residents. Residents confirmed that the home met their needs. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.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 The deployment and numbers of staff available at the home are sufficient to meet the needs of the residents. EVIDENCE: Four weeks worth of roters were examined. This showed that four care staff were on the morning shift and three care staff were on the afternoon shift. In the evening this went up to four care staff. At night there was two awake care staff. The home employed kitchen staff seven days a week, cleaning, and housekeeping staff six days a week. The roter also stated who from the management team was on call. These staffing levels were appropriate to meet the needs of the residents. Residents spoken with confirmed that there was always enough staff when they needed them. A new Senior Carer had started on the day of inspection and was completing her induction. The home have developed a policy on recruitment and employment including redundancy. It was recommended that further details relating to checks required by regulation be added to reflect the recent changes made last year. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 18 The home also had a new policy on equal opportunities and racial harassment available for inspection. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.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) 31,32,37 and 38 People who use this service can expect to find a well run service that is in the best interests of the residents, where welfare and safety is promoted. EVIDENCE: At this inspection there was the unusual situation where there was the existing registered manager in post and she was due to retire at the end of that week and the new manager who had been found ‘fit’ by the CSCI. This was because the management had planned succession management for the home to ensure a smooth transition from one manager to another. This according to both staff and residents had worked well. There were celebrations to commemorate the retirement of the existing manager in which both staff and residents were participating. The new manager was suitably confident and cooperative with the inspection process. Both residents and staff felt the new manager was approachable and
Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 20 looked forward to her managing. The new manager had enrolled on the NVQ 4 in care management and was progressing as expected. As stated through out this report the home has developed all the required policies and procedures expected to be in place and these were available for inspection. A new policy developed was that on record keeping. It was recommended that when this is next reviewed this should include a list of all records to be kept in care home as stated by regulation. Health and safety was seen to be promoted in terms of the equipment supplied for staff use, the risk assessments for each individual, the safe hot water temperatures maintained, the good maintenance of the environment and appropriate policies such as Aggression Towards Staff was in place. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.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 x 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 x x x x 3 3 Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 22 yes 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 9 Regulation 13(2) Requirement Medicines within the custody of the home must be handled in accordance with regulations. Timescale for action 30/06/05 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 3 37 Good Practice Recommendations All documentation should have the date on which it was completed. e.g pre admission assessment. When the policy on Record Keeping is next reviewed it should contain the list of all records to be kept in a care home. Bethesda Eventide Homes v224884 i54 i04 s24337 bethesda v224884 200405 stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection 5th Floor, St Vincent House Cutler Street Ipswich IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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