Inspection on 30/05/07 for Bethesda Eventide Homes

This inspection was carried out on 30th May 2007.

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 Eventide Homes 09/09/05

Bethesda Eventide Homes 20/04/05

Bethesda Eventide Homes 22/09/04

Bethesda Eventide Homes 05/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Bethesda Eventide Homes 59a Henley Road Ipswich Suffolk IP1 3SN Lead Inspector Cecilia McKillop Unannounced Inspection 30th May 2007 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 Eventide Homes DS0000024337.V342310.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 Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethesda Eventide Homes Address 59a Henley Road Ipswich Suffolk IP1 3SN 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) 01473 211431 F/P 01473 211431 eventide@btconnect.com None available. Bethesda Eventide Homes Mrs Barbara Christine Durrant Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th September 2005 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 well-maintained garden that is accessible through the lounge and conservatory. Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced inspection, which was conducted over a five hour period. A tour of the home was undertaken and care practice observed. Five residents were spoken with about life in the home. Staff were interviewed, and a sample of records were examined. The inspector also spoke with the registered person who was visiting the home on the day of the inspection. Prior to the inspection the manager completed a pre-inspection questionnaire and questionnaires were received from residents and their relatives. The homes fees range between £380 and £420, depending on the room. What the service does well: What has improved since the last inspection? Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 6 Since the last inspection the home has continued to upgrade and develop the administrative systems. One of the bathrooms has been fitted with a new bath and hoist. A system of formal supervision for staff has begun and progress will be followed up at a future inspection. 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 Eventide Homes DS0000024337.V342310.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 Eventide Homes DS0000024337.V342310.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): 2,3,6 Quality in this outcome area is excellent. People who use this service can expect to be provided with information about the home and to have their needs assessed prior to their admission. Efforts are made to personalise and manage the process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector was shown a copy of the resident’s information folder, which is provided, to new residents. This contains the statement of purpose, an application form and a copy of the preadmission assessment. A newly admitted resident who was interviewed as part of the inspection said that she had visited the home prior to her admission and had stayed for lunch. Residents who completed the questionnaire reported that they had received enough information about the home before they moved in. Resident’s files which were examined as part of the inspection contained a copy of a pre-admission assessment. The manager said that this is usually completed on a home visit, which is undertaken, by the manager and one of the trustees Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 9 There were checklists on the residents’ files which had been signed of to ensure that admissions were well managed and that small matters were not overlooked. There was good attention to detail. Residents’ files contained a copy of their contract outlining the room and conditions of residence. Bethesda Eventide Homes DS0000024337.V342310.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 good. People who use this service can expect to a plan of care for their daily requirements and to have their needs met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents records were examined as part of the inspection. The care plans, which were in place, were detailed and informative. The plans gave clear instructions on how care should be delivered to meet resident’s needs and clearly outlined residents care preferences. There were risk assessments in place with regard to pressure care, nutrition and moving and handling. There was evidence of ongoing monitoring of key areas and of regular reviews. Residents’ records documented health needs and there was evidence both from talking with residents and in the documentation of residents having regular access to opticians, dentists and chiropodists. Documented sheets with key Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 11 medical details were available on residents’ files should a resident have to attend hospital in an emergency. Medication was found to be stored securely and there were clear arrangements in place for the recording ordering and checking of medication. A sample of medication administration sheets (MAR) were examined as part of the inspection and there was no evidence of any errors. Resident’s photographs are placed with the MAR sheets and on boxes containing some of the medication as additional safeguards. The inspector was informed that one resident has retained responsibility for their own medication and lockable storage facilities are provided. Residents interviewed spoke highly of the care they received from staff and said that staff were good as respecting their privacy. Comments which were made included the following “ I am well looked after” “I am looked after wonderfully well” “Everything is done for the patients comfort”. Feedback from the questionnaires was also very positive. The Commission received 21 ‘have your say questionnaires’ of which 20 said that they “always ” received the care and support that they needed. Eighteen relatives questionnaires were returned to the Commission and these were also very positive with a number of them describing the homes as excellent “a wonderful place” Bethesda Eventide Homes DS0000024337.V342310.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. People who use this service can expect that the lifestyle and catering on offer with match their expectations and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s rooms are called their “home ” and staff were observed knocking and waiting before entering. Care plans clearly document residents’ preferences for their care and their social interests. The home has a very clear Christian ethos based on the teachings of the Baptist Church. A number of the organised activities relate to Bible study groups and devotion. Other activities are also organised and there had been a fashion show due to take place the day before the inspection, which unfortunately had to be cancelled. The inspector was informed that a number of outings had been organised for the next few months, which included trips to the seaside and a river cruise. Seventeen residents who completed the questionnaire indicated that they were happy with the level of activities. Two residents said that there was usually enough but one resident said that they would like some more. Relatives and visitors were observed coming and going throughout he day of the inspection. Residents reported that their visitors were made to feel Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 13 welcome and always offered a cup of tea. Two residents were observed going out for their daily walk and the inspector was informed that a number of the residents go out to lunch clubs and their church events. The manager said moving into the home “is a change of address and they try and maintain residents existing lifestyle ”. The meal served on the day of the inspection was gammon and pineapple with peas and mash. A number of the residents had chosen fish cakes as an alternative. Residents interviewed said that the food was tasty and of good quality. Residents were also positive in the questionnaires. Fruit crumble was served for pudding. Home made cakes were noted to be available. Staff interviewed confirmed that they had undertaken food hygiene training. Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. People who use this service can expect to have any complaint handled properly and be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure was on display and the manager said that there had been no recent complaints. Residents who completed the questionnaire reported that they knew how to make a complaint should they wish to. The manager informed the inspector that she had undertaken a course on the protection of vulnerable adults and had an up to date copy of the local procedures. Staff interviewed reported that they were aware of the POVA procedure. The manager said that she completes a report for the homes trustees every month. Two of the homes trustees were visiting the home on the day of the inspection. Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,26. Quality in this outcome area is excellent. People who live at this home can expect a clean comfortable environment and to have equipment made available to them to maximise their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Bethesda offers an environment, which is appropriate and well maintained. The communal areas were homely in appearance and comfortable. Three “homes” or bedrooms were seen. They were well decorated and furnished and like all areas in the home were clean. The homes had been personalised with personal processions and furniture. Bethesda has a number of shared “homes ” but the inspector was informed that these are only used by residents who specifically request to share. Rooms have ensuite facilties. Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 16 Specially adapted baths are available one of which is a tilting bath. One of the residents interviewed spoke of how they enjoyed the whirlpool bath. The inspector was informed that pressure mats are available for residents who are at risk of falling at night. A significant number of residents have been provided with an individual mobile call bell, which a number of residents said they found reassuring. The laundry was visited as part of the inspection and contained a manual sluice and a number of washers and dryers. The laundry was well ordered and clean. The inspector was informed that there are plans to upgrade the laundry facilities. Gloves, aprons, liquid soap and paper towels were available throughout the home. Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 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 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. People who use this service can be confident that they will be cared for by sufficient numbers of trained staff. Recruitment is essentially sound but could be strengthened. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the morning of the unannounced inspection there were three carers and a senior on duty. Staff were observed responding to residents needs in an unhurried manner. Staff who were interviewed reported that the levels of staffing was sufficient to meet the needs of the residents accommodated. Residents said that there was sufficient numbers of staff around and if they ever had to wait it was for a short period. The home had one staffing vacancy and were interviewing on the day of the inspection. The recruitment records for one member of staff was examined as part of the inspection and there was an application form, interview records and a criminal record bureau check in place. The criminal record bureau check and the professional reference had been received before the member of staff had started work, but the home had difficulty obtaining a second reference despite making a number of requests. The home had asked the member of staff to Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 18 provide the name of an additional referee, although the member of staff had been working at the home for some months. The inspector was informed that all newly appointed staff have a period of induction which involving shadowing more experienced staff and working with buddy . The manager said that she was in process of developing a new in house induction programme for staff which correlates with the common induction standards. The inspector was shown questionnaires, which staff will complete to demonstrate competency. The inspector was informed that 60 of staff have achieved NVQ level 2. Staff interviewed conformed that they had received training in manual handling, POVA , food hygiene, first aid and fire. Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. People who use this service can expect to find a well-run service that runs in the best interests of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was available on the day of the inspection and was positive and constructive. The manager has worked at the home for a number of years as a senior carer prior to her appointment as manager and was able to demonstrate during the inspection that she was familiar with the needs of older people. The manager has undertaken a NVQ4 in Care and the Registered Managers award. The home reviews the quality of the care in a number of ways. Through the use of resident meetings, questionnaires and monthly reports by the manager to the Trustees. Several trustees are involved in the home in differing Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 20 capacities and see first hand how the home is operating. Two trustees were visiting the home on the day of the inspection and the registered person was interviewed as part of the process. The trustees do not currently provide formal feedback on the results of the questionnaire and it was agreed that this was an area that they could take forward. Staff interviewed were positive about the support available to them in their role and said that the managers door was always open. The manager has begun the process of regular staff appraisals and was in the process of setting up a programme of regular supervision for staff. The home assists residents to look after their personal money. The inspector found that this was being kept securely and there were clear arrangements in place for access and auditing, including two staff signatures and receipts for purchases. A certificate of public liability was on display. There was written evidence of regular checks being undertaken on fire safety equipment. A fire safety risk assessment had been undertaken. The inspector was shown a copy of a letter that the home had received following a recent inspection of the premises by the fire officer. Two matters had been identified and the manager confirmed that these were in the process of being addressed. The manager provided the inspector with dates of the chair lift and shaft lift servicing. There was evidence from case tracking of risk management systems being in place and pressure pads and individual call bells are provided to minimise risks of falling. Clear systems were in place with regard to infection control and staff training. Water temperatures were tested on the day of the inspection and were within the recommended levels. The inspector was informed that regular checks are undertaken on water temperatures and before residents are bathed. The inspector noted that the bath mixed valve was assessable to residents and staff and recommended that the risk associated with people inadvertently changing the temperature are examined as part of the risk assessment process. Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 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 3 X 3 4 3 4 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bethesda Eventide Homes DS0000024337.V342310.R01.S.doc Version 5.2 Page 22 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 OP29 OP33 Good Practice Recommendations Where personal referees do not respond to reference requests a further reference should be sought as soon as possible, and prior to the member of staff starting work The outcome of quality audits should be made available to service users and other interested parties. 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