Inspection on 09/09/05 for Bethesda Eventide Homes

This inspection was carried out on 9th September 2005.

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

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

Other inspections for this house

Bethesda Eventide Homes 30/05/07

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 Claire Hutton Unannounced Inspection 9th September 2005 09:45 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.V250610.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 Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 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 01473 211431 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.V250610.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 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.V250610.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a weekday in September and lasted 4 hours. Six staff were spoken with, some in private. The manager was out assessing a potential resident for the home at the beginning of the inspection, but was available for discussion in the afternoon and for feedback. The inspector met some residents and spoke to one resident and one visitor in private. All communal areas of the home were seen, including the kitchens. One bedroom was also visited with the permission of the resident. Records inspected included staff recruitment, rosters and training, resident’s records including care plans and finance records. Policy and procedures relating to medication and catering were also seen. Any key standards not assessed in this report can be found in the previous report from 20th April 2005. What the service does well: What has improved since the last inspection? Since the last inspection the CSCI pharmacy inspector visited the home on 17th June 2005. From that inspection came four requirements and five recommendations. At this inspection all these requirements have been addressed. The system of administration and storage of medication has been brought up to date and now completely conforms to what is expected. The manager has worked closely with the relatively new appointed administration person at the home. There have been developments in the presentation of the roster. This is now colour coded and any change can easily Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 6 be seen and traced as well as showing who is on duty at any time. Also staff records have been reviewed and small changes made to ensure confidentiality. 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 DS0000024337.V250610.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 Eventide Homes DS0000024337.V250610.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): 3 People who use this service can expect to have their needs assessed before they move into the service and therefore can expect to have their needs met. EVIDENCE: The manager was out at the beginning of this inspection and she was visiting a potential resident to move into the home. At the last inspection it was confirmed that this was generally the case that residents would get a visit from the manager to assess care needs as well as obtain a social work assessment were applicable. One file was examined and an assessment was seen to be completed before the resident moved into the home. Bethesda Eventide Homes DS0000024337.V250610.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): 7 and 9 People who use this service can expect their care needs and medication needs to be well thought through and individualised, therefore making it more likely that their requirements will be met. EVIDENCE: The care plan for one individual was looked at. The home have introduced a new streamline format for the care plans that show staff instantly what individuals care needs are and clear instructions on what they must do. There was evidence of regular review. The same resident was spoken with and asked if staff knew how to care for them individually. The answer was ‘yes, all staff knew and that she was very happy with the level of care’. The home have a new policy and procedure on medication. A copy was given to the CSCI. This appears to be comprehensive and starts with the premise that residents may keep and self-administer their own medication if they are competent and so desire. Ordering, receipt, storage, and disposal of medication are all in the policy. The process for administration and recording medication is clearly set out. This includes what to do for controlled medication and if there are any errors. Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 10 Appropriate storage facilities are in each person’s room as well as appropriate storage for transporting medication around the home and storing medication, including a fridge. The policy sets out staff training for medication and the level of supervision required to deem staff competent. Staff were observed giving medication from the trolley and securing this away after use. The newly built store cupboard has been well thought out, but the shelving was raw MDF that would allow liquid medication to soak in if spilt. Records seen were up to date and accurate. Bethesda Eventide Homes DS0000024337.V250610.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): 14 and 15 People who use this service can expect that the lifestyle and catering on offer will match their expectations and preferences. EVIDENCE: Several areas relating to choice and control over life were looked into. The home starts with the premise in their new policy that residents can self medicate. The care plans set out individual preferences about how they like being cared for. One resident spoken with said they can determine when they get up or retire to bed. One aspect the resident particularly liked was staff who knocked on her door and then waited to be asked to come into the room. In the kitchen there were photographs of the residents and underneath were individual preferences about how they liked food and drink to be served. One resident confirmed a choice of meals were always available. The home have a sample menu available from which residents choose their preferred option. This was then seen to be recorded. The kitchen was beautifully clean with all schedules of cleaning and records of temperatures from cooking and storing food appropriately kept. There were adequate stores of good quality food that catered for the choices on the menu. There are deliveries of fresh food twice a week. There is a bowl of fruit near the dining room for resident to help themselves at any time. A resident conformed that they can request a drink at any time and that the food is consistently good. Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 12 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): 16 and 18 People who use this service can expect 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 Users Guide) There had been no recent complaints and there were none outstanding. Residents spoken with had no complaints and did not have any dissatisfaction with the service on offer. Any matters that the Inspector has raised with the organisation have always been promptly attended to. The home has a procedure on protection of vulnerable adults. This is the one published by Suffolk Social Services. The copy at the home was the older version and a new updated copy is available. The homes manager agreed to obtain a copy. Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 13 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, 20, 21, 22, 23, 24, 25 and 26 People who use this service can expect to have a comfortable, safe and wellmaintained home that meets their needs. EVIDENCE: Bethesda continues to offer an environment that is appropriate and well maintained and meets all the above standards. The communal areas were homely in appearance and the chairs were comfortable for the residents. Residents confirmed that the home met their needs. One individual bedroom was seen. This was both well decorated and furnished. Like all areas of the home this was clean and fresh in appearance. The room was individualised and had personal possessions and furniture in. The resident was very proud of the room and pleased to show it. The resident confirmed that their room and bathing facilities met their needs. Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 14 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): 27, 29 and 30 People who use this service can be confident that there will be sufficient staff on duty that are well recruited and trained. EVIDENCE: The manager and administration assistant had developed a new format for the roster that was colour coded. The new system was easy to follow any changes that had occurred such as training, annual leave or staff sickness. The current roster 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 care staff awake. The home employed kitchen staff seven days a week, cleaning, and housekeeping staff six days a week. The roster 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. The visiting District Nurse said ‘staff always answer the door promptly and are helpful’. The recruitment records for three new staff were examined. These were in order and held all the correct checks required. There was evidence of induction training for new staff and evidence of induction at the home when the new staff shadowed other staff members. Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 15 Seven staff at the home have NVQ 2. Two more people were due to complete very shortly and one other person had obtained a place to start NVQ 2. The manager is an assessor and is keen to see staff develop this qualification. The manager spoke of her plans to develop a three-year training strategy. The plan will show who at the home has what training and when in the three-year time span this is due for renewal. Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 16 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): 31,33 and 35 People who use this service can expect to find a well-run service that runs in the best interests of the residents. EVIDENCE: The manager Mrs Barbara Durrant was available for part of this inspection. Her attitude to inspection is positive and welcoming. Mrs Durrant confirmed good progress with her qualification NVQ 4 in care management. The changes Mrs Durrant has introduced around medication have been swift and appropriate. The main lead in rewriting the medication policy and procedure has come from Mrs Durrant, but staff spoken with welcome the changes. Staff and residents spoken with were pleased with the transition from one manager to the new one. However, as part of the homes quality assurance relatives and residents will be asked about their view on how the transition has gone. The home manages and reviews quality in a number of ways. Previously a questionnaire was circulated for residents about catering and another one Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 17 about social activities. The manager produces a monthly report that goes to the trustees. Indeed several trustees are involved in the home in differing capacities therefore they see first hand how the home is operating. The CSCI receive regular monthly reports in the form of regulation 26 visits. The manager contacted the CSCI after the inspection and confirmed that the home now have a fax machine. The home helps residents to manage their personal money. This is kept securely in a safe. Staff were seen to access this throughout the day. Records for money held were kept along with receipts and the signature of two staff. The manager confirmed the home does not have any other interests in residents money other that dealing with small amounts of petty cash. Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 18 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 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 x Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 19 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 3 Refer to Standard OP9 OP18 OP37 Good Practice Recommendations The shelf in the medication cupboard should be painted or have a covering that does not allow medication to soak in or stain. The revised policy on protection of vulnerable adults should be obtained from Suffolk Social Care Services. When the policy on Record Keeping is next reviewed it should contain the list of all records to be kept in a care home. (repeated from 20/10/05) Bethesda Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Eventide Homes DS0000024337.V250610.R01.S.doc Version 5.0 Page 21 - 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!