Inspection on 15/04/05 for Bethesda Home

This inspection was carried out on 15th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bethesda Home 06/09/07

Bethesda Home 27/07/06

Bethesda Home 06/10/05

Bethesda Home 18/11/04

Bethesda Home 17/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Bethesda 5 Hove Park Gardens Hove East Sussex BN3 6HN Lead Inspector Merle Blakeley Unannounced 15 April 2005 10:00 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Bethesda Home Address 5 Hove Park Gardens Hove East Sussex BN3 6HN 01273 735735 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) Trustees of Gospel Standard Bethesda Fund Vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (OP) 21 of places Bethesda Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of service users accommodated must not exceed 21 2. The service users accommodated will be aged 65 years or over on admission Date of last inspection 18 November 2004 Brief Description of the Service: Bethesda is one of four care homes owned by the Trustees of Gospel Standard Bethesda Fund. The home is registered to care for up to 21 older people who require assistance and support in their everyday lives. The home is not registered to provide nursing care. One of the conditions of residency is that residents are members of the Gospel Standard Churches or that they regularly attend their chapels. The home comprises of a large three-storey property, which is set back from the Old Shoreham Road next to Hove Park, the area is quiet and peaceful. All bedrooms have en suites and they are all located on the ground floor. There are also assisted baths and walk-in showers. The home has a dedicated Bethesda library and a pleasant rear garden area, which is accessible to all residents. The home also has the use of a communal mini bus. Bethesda Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection took place over a period of five hours on 15th April 2005. The inspection process included speaking to eight of the fourteen residents, a brief chat with two visitors, a tour of the premises, document reading and informal talks with all the staff on duty. What the service does well: What has improved since the last inspection? The home is continuing to improve the care planning records for residents and several drafts were seen during the inspection. It is hoped that a new care plan will be in operation at the next inspection. These new plans will help to make information about residents more easily understood, as the current records appear confusing and often information is duplicated. All overseas staff that are working at the home on a temporary basis now receive CRB checks before they commence employment. Recruitment records have also improved but still need to include references for all staff, regardless of how long they have been working at the home. Bethesda Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bethesda Version 1.10 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 Version 1.10 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 & 4 The home provides each resident with a contract and a statement of terms and conditions. Pre-Admission Care Needs Assessments are carried out on all new residents prior to moving into the home; this enables both the home and the resident to decide whether the home can meet their needs. EVIDENCE: All residents are provided with individual contracts plus the terms and conditions. Random contracts were viewed during the inspection and they all included relevant information regarding trial periods, charges, payments, holiday absences, admissions to hospital, meals, pets, visitors, repairs, reading & prayer, burial, right of information etc. Before a new resident moves into the home a Pre-Admission visit is carried out. This visit involves a representative from the home, usually the Registered Manager, assessing the prospective resident to ensure that all their needs can be met by the home. A comprehensive form is used to record important information about the resident and covers such topics as mobility, social life, physical health, hygiene, medication, dietary needs, mental and emotional health, safety risks and current and past illnesses. Family members or friends are able to be present at these assessments. Bethesda Version 1.10 Page 9 Bethesda Version 1.10 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 Individual care plans provide relevant and up to date information regarding each resident. Medication records were found to be in order however, risk assessments must be carried out on all residents who self medicate. EVIDENCE: The senior staff team are currently in the process of designing new care plans for residents. During the last inspection it was noted that although the home records all the relevant information on residents the plans were complicated because not all the information was kept together. The staff are now trying to update the care plans to make them more user-friendly. All care plans that were viewed on the day provided relevant and up to date information on each resident. The health care needs of one particular resident are quite high at the moment and district nurses and other professionals are now involved. Staff stated that they were able to provide the care needed for this resident, which was only expected to be short-term. All residents are registered with their own doctor and staff will accompany residents to all medical appointments. The home has a dedicated safe storage room for medications and this area was viewed. Medication records were checked and found to be in order. There are some residents who self medicate but no risk assessments have been carried out on them. Whilst self-medication is encouraged where appropriate, the Bethesda Version 1.10 Page 11 home must carry out a risk assessment to ensure that the person is fully able to take responsibility for his or her own medicines. Bethesda Version 1.10 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, 14 & 15 The lifestyle within the home is in keeping with The Gospel Standards Strict Baptists teachings. All residents agree to live in a sober and godly manner according to their faith. Residents have a good level of involvement within the home. Overall, residents appeared happy with the meals that were provided, however some stated that they were not always aware of the alternative choices available at mealtimes. EVIDENCE: The home employs an activities co-ordinator three mornings a week and she organises tabletop past times in the lounge room for residents. The coordinator is intending to compile a list on what activities each resident likes and dislikes. Some residents spoken to say that they would like to go out on more excursions; the home does have its own minibus transport. During the day residents are also involved with the daily prayer readings in the lounge and for those who prefer to stay in their rooms a relay system allows them to listen in to the lesson. Residents felt that they were given choices and all felt that they had control over their own lives. All residents were seen to be registered on the electoral roll. The menu for the home appeared quite varied and it is changed regularly. During the lunchtime period eight residents were seen eating in the dining room with the remainder preferring to eat in their rooms. All residents spoken to said they were happy with the meals provided, some residents did not appear to be clear about whether other meal options Bethesda Version 1.10 Page 13 were available. The menu is displayed daily. The home can cater for certain dietary needs. Bethesda Version 1.10 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 The home has a complaints policy and procedure. EVIDENCE: The homes complaints policy and procedure clearly states how residents can make a complaint and whom they can go to. The policy also states that all complaints will be responded to within a maximum of 28 days. The home has not received any complaints. Bethesda Version 1.10 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, 21, 24, 25 & 26 The home is well laid out and all bedrooms are on the ground floor. A full time maintenance person ensures that the home is safe and maintained to a high standard. All bedrooms are en suite and provide comfortable, individualised accommodation. The home is kept clean and tidy and free of any offensive odours. EVIDENCE: The home is well appointed and because it is set back from a very busy main road in Hove, it is quiet and tranquil and this aspect is what most residents appreciate about the home. All bedrooms are located on the ground floor and therefore suitable for wheelchair access. The bedrooms are all en suite and residents have personalised their rooms with their own pieces of furniture and small belongings. Each room is also fitted with a relay system, which enables residents to listen to prayers and bible readings in their rooms if they do not wish to go to the lounge area. Some of the rooms look out onto a very pleasant garden/courtyard area. As well as their own private facilities residents have use of the three bathrooms in the home; one of which is an assisted Bethesda Version 1.10 Page 16 bath. The home employs a maintenance person who ensures that the home is maintained to a very high standard. Hot water temperatures are recorded weekly, so that hot water can be delivered and maintained at the correct temperature. Bethesda Version 1.10 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, 28 & 29 There appears to be sufficient numbers of staff on duty to meet service users needs. The home has an excellent level of NVQ trained staff who work well together as a team. The area of recruitment and record maintenance has improved, however some of the staff still do not have references on file. EVIDENCE: The home continues to maintain a good staff team who have worked at the home for a number of years. The staff rota provides three staff on duty in the morning and in the afternoon. One waking and one sleeping night staff are provided for the night cover. A part-time cook and ancillary staff are also employed during the day. The home had recently been short staffed but a senior staff member stated that the home was now back to being fully staffed. The home has an excellent record of providing NVQ Training for staff and approximately 90 of staff hold NVQ Level 2 Qualifications and above. Many are now commencing NVQ Level 4 Training, which is very commendable. During the last inspection the home was not maintaining adequate employment history records for staff. This area has improved, however the home still needs to ensure that all staff have references on file. Some of the staff members who have been employed at the home for several years do not have any references at all. All staff had undertaken CRB checks. When residents were asked about how they were cared for by staff the responses were very positive. A lot of residents spoke very warmly about how well they were looked after by the staff team. Bethesda Version 1.10 Page 18 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, 33, 35, 36 & 38 The home has been without a Registered Manager since October 2004, however the senior staff members have been working extremely hard to ensure that the home continues to be run in professional and caring manner. Quality assurance and monitoring systems are carried out by the home, which involve residents. Regular staff supervision has yet to commence. EVIDENCE: The Bethesda Fund Committee is currently recruiting to employ a full time Home Manager. Originally the Deputy Manager was to take up this post but she has since declined the position. The home has been without a Manager for approximately seven months and senior staff have worked very well together as a team to maintain a very good standard of care. Although staff stated that they were happy to carry out some additional duties, this is not an ideal situation for the home to be in for the long term. Residents were asked about how the lack of a Home Manager affected the care they received. All stated Bethesda Version 1.10 Page 19 that they continued to be well looked after and they felt that the care provided had not been compromised by the home not having a Manager. To ensure the continued quality of care within the home visits are made on a monthly basis by one of the Bethesda Committee members. These reports comment on staff, residents and the environment and are sent to the CSCI. Residents meetings are held on a six-weekly basis and here residents can voice their opinions or concerns about how the home is being run. The vast majority of residents look after their own finances with the help of relatives and friends and therefore the home only looks after the ‘pocket money’ for two residents. These records were checked and were found to be correct. Staff supervision sessions are due to start shortly with the deputy manager supervising senior staff and one of the senior staff providing supervision for care workers. The role of providing supervision sessions for staff should ideally be carried out by the Manager and not by the care staff. The home continues to maintain the health, safety and welfare of all residents and staff and there were no concerns raised during this inspection. Bethesda Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 3 x x 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 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 1 x 3 x 3 2 x 3 Bethesda Version 1.10 Page 21 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 OP29 Regulation Schedule 2 8 13(4) Requirement That the home requests and maintains references for all staff members. (previous timescale 28/02/05) That the home appoints a suitably qualified and experienced Manager. That risk assessments are carried out on all service users who self medicate. Timescale for action new timescale 30/06/05 Immediate Immediate 2. 3. OP31 OP9 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. Refer to Standard OP15 Good Practice Recommendations That residents are informed on a daily basis regarding the alternative meal options that are available. Bethesda Version 1.10 Page 22 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Version 1.10 Page 23 - 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!