Inspection on 06/10/05 for Bethesda Home

This inspection was carried out on 6th October 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 Home 06/09/07

Bethesda Home 27/07/06

Bethesda Home 15/04/05

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 Home 5 Hove Park Gardens Hove East Sussex BN3 6HN Lead Inspector Merle Blakeley Announced Inspection 6th October 2005 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 Home DS0000014179.V250398.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 Home DS0000014179.V250398.R01.S.doc Version 5.0 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 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Bethesda Home DS0000014179.V250398.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty one (21). Service users must be older people aged 65 years or over on admission. 15th April 2005 Date of last inspection 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 Home DS0000014179.V250398.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection was carried out over a period of five hours on the 6th October 2005. This report should be read in conjunction with the previous report from 15th April 2005. The inspection process included informal chats and lunch with several residents, a tour of the premises, document reading and informal talks with the Manager, the Home Chairman and staff who were on duty at the time. Prior to this Announced Inspection a pre-inspection questionnaire was returned along with eleven service user comment cards and four relative/friends comment cards. All the returned comment cards were found to be very positive with only one comment regarding the choice of meals available. There are currently fifteen people residing in Brighton & Hove Bethesda home. What the service does well: What has improved since the last inspection? The home has now appointed a manager who has been working for Bethesda since 1997, she was previously in the role of acting manager and she has recently obtained the NVQ Level 4 in Care and Management. New care plans have been introduced over the past few months and they were seen to be very comprehensive and easy to read. Staff stated that these care plans were much easier to complete and update. Risk assessments are now being carried out and regularly reviewed for all residents who self medicate. The home has also recently updated its recruitment files so that they comply with Schedule 2 of The National Minimum Standards. A recommendation was made during the last inspection for the home to inform residents about daily meal options, this has been carried out by displaying meal options in the dining room and by staff verbally informing residents. Bethesda Home DS0000014179.V250398.R01.S.doc Version 5.0 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.V250398.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 Home DS0000014179.V250398.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): 1,2 & 5. Intermediate care is not provided. The statement of purpose and service user’s guide has recently been updated. New residents are assessed before they move into the home. Prospective residents are offered visits prior to moving in. EVIDENCE: The Bethesda Homes Statement of Purpose and Service User’s Guide was recently updated in April 2005 and contains very detailed information regarding all aspects of life within the home. Before a resident can move into the home a full assessment is carried out to ensure that the home can meet the person’s needs. The Registered Manager normally carries out the assessment and it covers the areas of personal care, mobility, diet, medication, continence, falls, mental and physical state etc. Prospective residents are offered visits to the home prior to permanently moving in and the first eight weeks are mutually recognised as a trial period. Resident’s family/and or friends are also welcome to visit the home to see if it will meet their relative’s needs. Bethesda Home DS0000014179.V250398.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, 9, 10 & 11 The home maintains informative and up to date care plans. Respect and dignity is provided to all residents. Resident’s wishes regarding illness and death are recorded. EVIDENCE: The home has commenced using a new care plan system and this appears to be working very well. Several care plans were viewed and they were well presented and very informative. Care plans are updated monthly during staff meetings and either the resident or family member will view and sign them. Daily diary entries for each resident are also carried out. A new medication trolley has been recently purchased and this is also proving to be very effective in the way medicines are being administered within the home. Risk assessments have now been carried out on all residents who self medicate and these will be reviewed on a regular basis. During the inspection it was evident that residents are treated with dignity and respect by the way staff entered bedrooms and addressed the residents. The Gospel Standard Strict Baptists have a very solemn objection to cremation and therefore all residents are asked to sign a form stating their directions for burial. If a resident should become ill, staff are always available to provide any Bethesda Home DS0000014179.V250398.R01.S.doc Version 5.0 Page 10 additional care needs. Visiting district nurses and other professionals would also provide their services if they should be needed, as the home does not provide nursing care. Bethesda Home DS0000014179.V250398.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): 13 & 15 Residents are able to maintain links with family and friends. Residents are offered a well balanced diet. EVIDENCE: Residents are encouraged to maintain their links with family, friends and the local community. Visitors are welcome at all reasonable times except that visiting is not encouraged on Sundays when chapel services are being held, however this is not a hard and fast rule as one resident has a family member who visits on a Sunday, as this is the only time he is able to come. A new cook has recently commenced employment at the home and residents who were spoken to on the day stated that they were very happy with the meals that were being provided. Meals options are now more readily available and they are displayed in the dining room with staff also verbally informing residents about the options available on that day. The inspector was able to enjoy lunch with some of the residents. Bethesda Home DS0000014179.V250398.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): 17 & 18 The home needs to provide residents with information about how they can contact an external advocate. All staff have received training in Adult Protection. EVIDENCE: The legal rights of residents were discussed with the manager. All residents are registered on the electoral roll and one resident has the use of an advocate. It was recommended during the inspection that all residents should be provided with information about how they can contact external advocates in case they should need one in the future. The manager stated that she would go around and ask all residents about their wishes regarding the use of advocates. There have been no adult protection issues within the home and all staff have recently attended training in this subject. Staff recruitment files revealed that all staff had undertaken CRB checks before commencing employment at Bethesda. Bethesda Home DS0000014179.V250398.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): 20, 22, 23 & 26 Adequate communal areas are provided. The home has been assessed by a qualified occupational therapist. Call bells need to be checked on a regular basis. Resident’s bedrooms are of a good size and are comfortable and homely. The home is clean and tidy and maintained to a high standard. EVIDENCE: The home has now been assessed by a qualified occupational therapist who reported that the home is providing all the necessary specialist equipment for residents. The home has a call bell system, however it was noted that these bells are not being checked on a regular basis. Communal areas within the home include a separate lounge and dining room, small sun lounge and a rear garden with a summerhouse and dedicated Bethesda library. All bedrooms within the home are provided with en suite facilities. The rooms are well appointed on the ground floor with level access and therefore suitable for wheelchair users. Several rooms have views out onto the rear garden area. Resident’s bedrooms were seen to be homely and comfortable and furnished with their own personal belongings. The home is very clean and tidy and maintained to a very high standard. Bethesda Home DS0000014179.V250398.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): 29 & 30 Recruitment files were inspected with a recommendation that application forms are updated. Staff receive a good level of training. EVIDENCE: The staff recruitment files were viewed and they now include all relevant information as set out in Schedule 2 of the National Minimum Standards. In discussion with the manager it was agreed that the current job application forms need updating to reflect current recruitment practises. Staff are provided with a good level of training and recently staff have attended courses in Adult Protection, Fire Safety, First Aid, Manual Handling, Medication, Supervision and ‘The Effects of Having a Stroke’. A number of staff are due to attend a course on Health & Safety. Bethesda Home DS0000014179.V250398.R01.S.doc Version 5.0 Page 15 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, 32, 36, 37 & 38 The Deputy Manager has now been appointed as the Registered Manager. The home is run in an open, friendly and caring manner. Supervision sessions commenced in August 2005. All the required records are being maintained. There were no major concerns regarding any Health & Safety issues within the home. EVIDENCE: During the last inspection it was reported that the home continued to be without a Registered Manager. This situation has now been resolved with the appointment of the Deputy Manager becoming the Registered Manager of this home. The Manager successfully underwent the CSCI registration process in August 2005. The Manager has been employed in the home for a number of years and she has successfully undertaken the NVQ Level 4 Qualification, she is hoping to complete the Registered Manager’s Award (RMA) by April 2006. Staff and residents were asked about the management approach of the home and all commented that the home is run in a friendly and caring manner. Bethesda Home DS0000014179.V250398.R01.S.doc Version 5.0 Page 16 Staff supervisions are now taking place on a regular basis and it is expected that these recorded sessions will be held at least six times a year. Staff appraisals are carried out on an annual basis. All the required records are maintained by the home. It was noted that fire drills do need to be carried out more frequently. The home has a dedicated staff member who acts as a fire warden and she will be arranging more frequent drills in the future. During the inspection there were no major concerns regarding any health & safety issues within the home. As mentioned previously the home does need to ensure that all resident’s call bells are checked periodically to ensure they are in good working order. Bethesda Home DS0000014179.V250398.R01.S.doc Version 5.0 Page 17 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 X 3 X 2 3 X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 3 3 Bethesda Home DS0000014179.V250398.R01.S.doc Version 5.0 Page 18 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 OP17 OP22 OP29 Good Practice Recommendations That service users are provided with information about how to contact local advocates. That service users call bells are checked on a more regular basis to ensure they remain in good working order. That job application forms are updated to reflect current recruitment practises. Bethesda Home DS0000014179.V250398.R01.S.doc Version 5.0 Page 19 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 © 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 Home DS0000014179.V250398.R01.S.doc Version 5.0 Page 20 - 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. 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