CARE HOMES FOR OLDER PEOPLE
Bethesda Home 5 Hove Park Gardens Hove East Sussex BN3 6HN Lead Inspector
Merle Blakeley Key Unannounced Inspection 27th July 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bethesda Home DS0000014179.V294868.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 Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bethesda Home Address 5 Hove Park Gardens Hove East Sussex BN3 6HN 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) 01273 735735 Trustees Of Gospel Standard Bethesda Fund Jeanette Christine Feaver Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty two (22). Service users must be older people aged 65 years or over on admission. 6th October 2005 Date of last inspection Brief Description of the Service: Bethesda is one of three care homes owned by the Trustees of Gospel Standard Bethesda Fund. The home is registered to care for up to 22 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. Fees currently range from approximately £348.00 to £418.00 per week. Additional charges are made for hairdressing and chiropody. Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over a period of seven hours on the 27th July 2006. As well as this site visit information was also gained from a pre-inspection questionnaire, residents survey forms, informal talks with seven residents, four staff and the manager. The site visit consisted of a tour of the premises, looking at the needs of five particular residents, document reading and observing staff and resident interactions. There are currently twenty residents residing at Bethesda. What the service does well: What has improved since the last inspection?
Three recommendations were made during the last inspection and these have all been acted upon. Residents will receive information about using advocates in the service users guide. Call bells are being checked on a regular basis and job applications have been updated to include more relevant information. Overall record keeping and the maintenance of files has improved and the office appears very well organised. The home has recently purchased new outdoor furniture, which residents have enjoyed during the warmer months. A new garden path has also been installed. Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 6 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 Home DS0000014179.V294868.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 Home DS0000014179.V294868.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments are carried out on all residents prior to them moving into the home. EVIDENCE: Before a prospective resident moves into the home an assessment of their needs is carried out. This assessment is to ensure that an individual’s needs can be met by the home. The inspector viewed the assessment documentation carried out on the last three residents who had recently moved into the home. They were thorough and contained good information about all aspects of the persons life. Residents needs vary from low, intermediate to high and fees are charged accordingly. Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 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, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Informative and up-to-date care plans are maintained. Residents current healthcare needs are being met. Medications are being administered correctly. Residents were seen to be treated with respect and dignity. EVIDENCE: Five care plans were viewed and the information they contained was significant and up-to-date. Care plans are updated and reviewed on a monthly basis. Risk assessments are carried out and these are also reviewed to see if any changes have occurred. Daily resident records are maintained. All staff who were spoken to appeared to have a good understanding of the needs of each resident. The home appears to be meeting the current healthcare needs of residents. Residents have access to their own GP, district nurses and chiropodists. Three of the residents are diabetic and they are receiving good support to manage their conditions effectively. The home has built up a good rapport with the local team of district nurses and staff have been provided with written information
Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 10 regarding diabetes, foot care and pressure sores. Two particular residents have a high risk of developing pressure sores. Medication records were checked and the home was found to be correctly and safely administering all medicines. There are seven designated staff members who administer medication and they have all received appropriate training. The medication trolley is securely stored within the home. There are some residents who self medicate and risk assessments have been carried out, however these risk assessments need to contain more in-depth information as to why the home feels the resident is able to manage their own medicines. These risk assessments need reviewing on a regular basis. During the day interactions between the staff and residents was observed and it was evident that staff treat all residents with dignity and respect. Resident’s wishes are taken into account regarding how their personal care is carried out and how they wish to be addressed. Residents who were spoken to also stated that staff treated them with respect and observed their privacy and dignity Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has made using available evidence including a visit to this service. Residents enjoy their lifestyles in the home. Visitors are made welcome in the home and residents are able to exercise choice and control over their lives. Residents enjoy a well-balanced diet. EVIDENCE: The home employs a part-time activities coordinator, who organises a number of activities for the residents. A number of excursions have been organised recently with opportunities to visit local places of interest. Within the home craft mornings and other activities are offered during the week. Bible readings and chapel visits also occur during the week. Those residents who are unable to go out have readings and services relayed to their rooms, so they are able to listen to them. Visitors are made welcome in the home at all reasonable times except that visiting is not encouraged on Sundays when chapel services are being held, however this can be flexible depending on the circumstances. Residents who were spoken to during the day felt that within reason they could exercise control and choice in their daily lives. They can make decisions about
Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 12 when they get up and go to bed, who carries out their personal care, if they wish to participate in activities, the meals they eat and where they eat and who they wish to see. The home will always try to ensure that they can help and support residents with any of their personal choices and decisions. All residents who were spoken with stated that they were happy with the meals that were being offered. Menus showed that residents were being provided with a well-balanced diet that included a variety of fresh produce. Special diets are being catered for. The daily menu and other meal options are displayed in the dining room. Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 13 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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints policy and procedure that needs to be displayed. An adult protection policy and procedure is in place. EVIDENCE: The home has written a policy and procedure regarding complaints. This document needs to be on display in an accessible area to residents and visitors. The manager stated that she talks to most residents each day and asks them if they have any issues, concerns or complaints. The complaints file showed that no complaints have been made to the home. The home also has a written policy and procedure regarding the protection of vulnerable adults. All of the staff have attended training in this subject and there have not been any adult protection issues within the home. All staff have a CRB check carried out before they commence employment in the home. Information regarding the use of advocates is to be included in the service users guide. Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 14 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, 22 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a friendly, safe and comfortable environment. The particular needs of the resident who has visual impairments requires assessing. The home is maintained to a good standard and is kept clean and tidy. EVIDENCE: The environment at Bethesda is very peaceful. Residents all have comfortable en suite bedrooms located on the ground floor. The home would be suitable for wheelchair users. A part-time maintenance person is employed and the home and grounds are maintained to a good standard. Most of the rooms have a very pleasant outlook onto the garden area. The home has recently purchased some new outdoor furniture, which included a gazebo. Residents stated that they enjoyed sitting out under the gazebo in the warmer weather. Since the last inspection a resident with visual impairments has recently moved into the home. The home must have this residents needs assessed for any additional aids she may need in her room and in communal areas to ensure that she can safely move around the home independently. During the
Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 15 day a member of staff needed to escort her to the dining room because she said she couldn’t ‘feel her way’ down the corridor. Some additional handrails and raised markers may be required to assist her in walking to the dining room and lounge and the home should contact a local organisation that can assist people with visual impairments. The home is kept clean and tidy throughout and there are no offensive odours. Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 16 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, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to review its night staff arrangements. Seven staff members have obtained NVQ qualifications. The home carries out suitable recruitment procedures. Staff receive a good level of training. EVIDENCE: The home continues to have a dedicated and committed staff team who provide a good level of care to residents. Staffing rotas indicate that there are four care staff on duty plus the manager in the morning and three staff in the afternoon with one waking night staff member. The number of people residing at Bethesda and their level of need has increased over the past few months and there are three residents who have high needs, one of whom is bedfast, eleven who have medium needs and six who have low needs. In discussion with some of the residents it was stated that many of them felt that there were not enough staff on duty during the night and that they often had to wait quite some time for the night staff member to attend them. This would indicate that one night staff member is not currently able to meet the needs of all the residents during the night. There are staff who live on site and they are rostered on to do sleep in duties, however their rooms are on another floor and they are normally only called out in an emergency situation. The home will be required to reassess the staffing levels during the nighttime period. As several permanent staff members are on annual leave the home is employing some agency staff. The home must ensure that the agency it is using is providing
Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 17 proof of the person’s details and their CRB check prior to them working in the home. The home currently employs seventeen care staff on a full and part-time basis. Seven of the staff team have obtained either the NVQ Level 2 or Level 3 qualification. Two senior staff have obtained NVQ Level 4 and the deputy manager is due to complete the Registered Managers Award in September this year. One staff member is a trained nurse. Two staff are due to commence NVQ training later in the year. Several staff recruitment files were viewed and they contain all the required information as set out in Schedule 2 of The National Minimum Standards. The home provides a good level of training and recent courses staff have attended include fire training, food hygiene, first aid and control of medicines. Infection control is currently being studied via distance learning and dementia training is to be held in September 2006. The home is also looking into staff attending training in continence awareness. Staff who were spoken to on the day said that they were very happy working at Bethesda and generally felt well supported and valued. Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 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 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, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is running the home in a friendly and supportive manner. The quality assurance programme needs to be expanded. Resident’s monies are securely stored within the home. The home is continuing to ensure that the health & safety of residents and staff is maintained. EVIDENCE: The registered manager is running the home in a friendly and proactive manner. She has obtained the NVQ Level 4 qualification and is currently studying for the Registered Managers Award, which she hopes to complete by September 2006. Both residents and staff felt the manager was supportive and approachable and that they could go to her if they had any concerns or issues to discuss.
Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 19 The home has a quality assurance programme, which needs to be expanded to include feedback survey forms from residents, visitors and visiting professionals. This will provide Bethesda with a wider range of feedback as to how well the home is performing and meeting expectations. Regulation 26 visits are carried out monthly and copies sent to the CSCI. These forms can now be kept on site for review at the next inspection. Residents meeting are held six times a year and the minutes are recorded. The home does not deal with resident’s finances as such, as family members and friends assist residents in this matter. Three residents keep small amounts of ‘pocket money’ in the home and these records were viewed. All the recorded amounts were checked and they were found to be correct. Resident’s monies are securely stored in the safe. The home carries out regular health & safety checks with call bells, hot water temperatures and fire alarms being checked weekly. The home has recently carried out a fire risk assessment in June 2006. A tour of the premises was carried out and no health & safety risks were identified. Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 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. 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 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP16 Regulation 22(5) Requirement That a copy of the homes complaints procedure is made accessible to all service users and visitors. That an assessment is carried out on the service user who has visual impairments to ensure that she is able to move around her room and the home independently. The home must ensure that adequate staffing levels are available during the night to meet the current needs of service users. To provide feedback survey questionnaires to service users, visitors and visiting professionals. Timescale for action 31/08/06 2 OP22 23(2)(n) 31/08/06 3 OP27 18(1)(a) 31/07/06 4 OP33 23(3) 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
DS0000014179.V294868.R01.S.doc Version 5.2 Page 22 Bethesda Home 1 Standard OP29 For the home to ensure that it receives adequate information prior to an agency staff member working in the home. Bethesda Home DS0000014179.V294868.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection East Sussex Area Office 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
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