Inspection on 06/09/07 for Bethesda Home

This inspection was carried out on 6th September 2007.

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

The inspector 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 27/07/06

Bethesda Home 06/10/05

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 Old Shoreham Road Hove East Sussex BN3 6HN Lead Inspector Nigel Thompson Key Unannounced Inspection 6th September 2007 09:00 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.V348293.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.V348293.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethesda Home Address 5 Hove Park Gardens Old Shoreham Road Hove East Sussex BN3 6HN 01273 735735 01273 735735 hove-bethesda@surfanytime.net 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) 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.V348293.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. 27th July 2006 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 suite facilities and are 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.V348293.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over five and a half hours in September 2007. It found that the majority of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken to during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were twenty residents living at the home. The inspection involved a tour of the premises, examination of the homes records and discussion with seven residents, three relatives, the manager and three members of staff. The focus of the inspection was on the quality of life for people who live at the home. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. What the service does well: The relaxed, homely and welcoming environment has evolved over several years and reflects the stability and commitment within the staff team, the efficiency and enthusiasm of the manager and her open and inclusive management style. Through working closely, sensitively and consistently with the residents, staff have developed a sound understanding of their individual care and support needs. Residents are encouraged and supported to make decisions about their lives. Where appropriate and practicable, they are involved and regularly consulted on many aspects of life in the home, including menu planning, colour schemes and activities. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 8 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.V348293.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The thorough admission policy and procedure ensures that residents are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective residents have the opportunity to visit the home and know that it is able to meet their individual care and support needs. EVIDENCE: Information for prospective residents, including the Statement of Purpose and the Service User Guide has been thoughtfully and imaginatively produced to a high standard and the combined document was found to be comprehensive and informative. It was noted that details had been most recently reviewed and updated in April 2007, so as to accurately reflect the services provided and the current situation within the home. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 10 Documentation, including comprehensive care needs assessments, relating to two most recent admissions to the home was inspected and found to be generally up to date and well maintained. As part of the admission procedure, the manager confirmed that prospective residents are invited to visit the home, to look around and meet with staff and existing residents. They also have the opportunity to stay overnight before moving in. A formal written contract has been developed and implemented and is routinely provided to each new resident or their representative, incorporating a statement of terms and conditions of residency. Residents, spoken with during the inspection, spoke positively about their experiences of moving into the home: ‘I couldn’t wish for a better place. There is nowhere else like it’. ‘The manager and staff here are so kind, they can’t do enough for you’. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans enable staff to meet the assessed needs of residents in a structured and consistent manner. Residents are protected by the home’s medication policies and procedures. They are treated with respect and encouraged to make decisions about their day-to-day living. EVIDENCE: The home operates an effective key-worker system. Personal care plans are in place for each resident and are clearly and directly linked to the individual’s assessed needs. Plans that were inspected were found to be accurate, generally well maintained, and up to date. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 12 The manager confirmed that residents or their relatives are involved or have the opportunity to be involved, in developing or reviewing their individual care plan. In plans that were examined, it was noted that records of monthly reviews are routinely signed by the resident, or their representative, as well as by the manager. ‘Notes to help the carer’ are kept in residents’ rooms and evidently provide comprehensive details of all personal care required and action to be taken by staff. Guidelines are also in place regarding residents’ individual morning and evening routines. All residents are registered with local GPs and have access to other health care professionals, including District Nurses and physiotherapists, as required, via the surgeries. However, it was noted that there is currently no structured recording of this and therefore, following discussion with the manager, it is recommended that appointments with, or visits by, health care professionals be appropriately recorded. Policies and procedures are in place for the control, storage, safe administering and recording of medication. However, in line with many other policies in the home, medication procedures (most recently revised in November 2001) must be reviewed and updated. The manager confirmed that all staff involved in administering medicines receive appropriate training. This was supported by documentary evidence and through discussions with care staff. As part of their induction programme, all staff receive instruction on the principles of dignity and respect. This was evident, through discussion during the inspection, and from direct observation of staff interacting with residents in a sensitive and professional manner. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled and supported to maintain contact with family and friends as they wish. They benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: Residents’ social and recreational interests and preferences are identified and recorded in their individual care plan, as part of the pre admission assessment process. An activities coordinator continues to work in the home three days a week and it was evident that a full programme of recreational and leisure activities has been developed. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 14 Independence continues to be promoted and encouraged within the home and the manager confirmed that, wherever possible, residents are enabled and supported to make choices and take decisions affecting their life and daily routines. Visiting in the home is evidently unrestricted and residents may see friends or relatives in the lounge or in the privacy of their own room. Residents continue to be provided with a varied, wholesome and nutritious diet. At lunchtime a choice of meals is available and special diets are catered for. A weekly menu is displayed, reflecting individual preferences and including seasonal variations. Positive comments received from residents during lunchtime indicated satisfaction with the standard of meals provided: ‘I like my food and it’s always good here.’ ‘We have been very satisfied with the food’. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The open and inclusive atmosphere within the home enables residents, staff and visitors to express any concerns, confident that they will be listened to and acted upon. Residents are safeguarded from abuse through relevant staff training, however outdated policies and procedures are unsatisfactory and must be reviewed. EVIDENCE: The manager continues to operate an ‘open door’ policy and is clearly considered to be very approachable and understanding. Residents and members of staff spoken to during the inspection confirmed that, should they have a concern or complaint, they would have no hesitation in speaking to the manager and each person was confident that they would be listened to. However, the home’s current complaints policy and procedure remain inadequate and unsatisfactory. Despite a previous requirement, there is still no evidence of an updated, concise and accessible complaints procedure having been developed and implemented for the benefit of residents, their friends, relatives and other visitors to the home. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 16 The home has produced policies and procedures relating to adult protection and abuse, including a whistle blowing policy. However, it was noted that the ‘Procedure for dealing with abuse of residents’ was last revised in November 2002. This is unsatisfactory and following discussion with the manager, it is required that, in line with other policies in the home, the policies and procedures relating to abuse and adult protection be reviewed and updated. The manager confirmed that the majority of staff have received specific adult protection training, in accordance with the multi agency guidelines for the protection of vulnerable adults. Further relevant training has been organised for the remaining staff for later in the year. However, although this was confirmed through discussions with members of staff during the inspection, there was little documentary evidence in place to support this, as individual and collective training records were found to be disorganised, inadequate and poorly maintained. . Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a calm and peaceful environment within the home and benefit from accommodation that is safe, comfortable, well maintained and decorated to a satisfactory standard. EVIDENCE: As with many of the environmental standards, the situation at Bethesda, regarding communal areas and residents’ accommodation remains largely unchanged with its calm and welcoming atmosphere. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 18 All residents’ bedrooms are located on the ground floor and have en-suite facilities. During my ‘guided tour’ of the premises, including residents’ accommodation and communal areas, it was evident that the well-maintained décor and adequate furniture and furnishings continue to provide a comfortable, pleasant and homely environment for the residents. A part-time maintenance man is employed at Bethesda and the home and grounds are maintained to a good standard. Most of the rooms look out onto the large, pleasant and easily accessible garden and during the inspection residents were observed enjoying a walk among the colourful and well-stocked flower-beds. Residents’ rooms were found to be clean, comfortable and generally well maintained. It was evident that many of the rooms have been personalised, with pictures, family photographs and other small items of furniture and belongings, to reflect individual taste, choice and preference. On the day of the inspection, it was evident that infection control procedures within the home are in place and are closely adhered to. Levels of cleanliness and hygiene remain generally high throughout. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is sufficient trained and competent staff on duty at all times to meet the assessed needs of the residents. The safety and protection of the residents is improved by robust recruitment procedures and appropriate staff training. EVIDENCE: Appropriate staffing levels are evidently in place to meet the current assessed care and support needs of residents. Staffing levels during the night have been reviewed, as required, since the previous inspection. An improved staff rota has been developed, showing details of which staff are on duty at any time and their designation. In addition to the comprehensive induction programme undertaken by all newly appointed staff, the manager confirmed that appropriate core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 20 The provision of such training was confirmed through discussions with staff, however documentary evidence was not in place to support this due to the inadequate training records. Following discussion with the manager, it is recommended that the recording of staff training be improved by the development and implementation of a structured training matrix. Dates and details of training received should also be recorded in individual staff files. As previously documented, it is evident, from discussions with members of staff that the manager operates an ‘open door’ policy, with staff feeling confident and able to discuss any issues at anytime. The manager is clearly aware of the need for thorough and robust recruitment procedures, to help ensure the safety and protection of service users. Staff files that were examined were found to be generally well maintained, containing necessary information, including proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from effective management and thorough quality assurance systems. Satisfactory health and safety policies and procedures, within the home, help to ensure the protection of residents and staff. EVIDENCE: The experienced manager has worked at Bethesda for ten years and has been in her current post since September 2005. She is evidently competent and qualified to run the home, having recently completed the Registered Manager’s Award (RMA). She also already holds the NVQ level 4 in Management and Care. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 22 She is clearly motivated, positive and approachable and has successfully developed an open and inclusive atmosphere within the home. From direct observation and through discussions with residents and members of staff, it is evident that the manager demonstrates a clear sense of leadership and direction and staff feel valued and supported by her: ‘She is a good manager, very helpful and supportive and always ready to listen.’ Effective quality monitoring and consultation with residents is ongoing and includes satisfaction questionnaires for residents, regarding the care they receive. Similar questionnaires are in place to obtain feedback from residents’ relatives and other visitors to the home. Positive responses to a recent survey indicate a high degree of satisfaction with the home and the services provided: ‘The care home is run to a very high standard. It has a very positive approach that is tailored to the individual needs of the clients. The kind, caring attitude of the home manager runs through all the staff with respect shown to all residents.’ ‘Bethesda is one of the most caring homes that I visit in my work and I feel residents’ needs are fully met.’ In accordance with Regulation 26, a member of the Home Committee routinely visits the home at least once a month, unannounced, to inspect the premises, speak with residents and staff and prepare a written report on the conduct of the home. A copy of this report is kept in the home and made available for inspection. The manager confirmed that the health, safety and welfare of residents and staff remains of paramount importance within the home. As previously documented, staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. Fire safety systems are regularly checked and outcomes recorded. All accidents are appropriately recorded and reported as required. Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 23 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 3 3 3 3 X 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 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 2 3 Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 It is required that a copy of the homes complaints procedure be made accessible to all residents and visitors to the home. (Previous timescale of 31.08.2006 not met). Timescale for action 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP8 OP30 Good Practice Recommendations It is recommended that appointments with, or visits by, health care professionals be appropriately recorded. It is recommended that the recording of staff training be improved by the development and implementation of a structured training matrix. Dates and details of training received should also be recorded in individual staff files. It is recommended that all policies and procedures be reviewed and updated, as discussed. 3. OP37 Bethesda Home DS0000014179.V348293.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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