Inspection on 13/05/05 for Bethesda House

This inspection was carried out on 13th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 House 08/01/09

Bethesda House 07/12/06

Bethesda House 08/11/05

Bethesda House 09/02/05

Bethesda House 09/09/04

Bethesda House 01/03/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Bethesda House Derry Hill Calne Wiltshire SN11 9NN Lead Inspector Alison Duffy Unannounced 13 and 24th May 2005 th 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 House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bethesda House Address Derry Hill Calne WIltshire SN11 9NN 01249 816666 01249 758877 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) The Gospel Bethesda Fund Miss Rebecca Wheeler Care Home 13 Category(ies) of OP Old Age (12) registration, with number PD Physical Disability (1) of places Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more then 12 service users over 65 years of age. 2. No more than 1 service user with physical disability. Date of last inspection 9th February 2005 Brief Description of the Service: Bethesda House is registered to provide care to thirteen older people, one of who may have a physical disability. The home is one of five throughout the country that is run by the Gospel Standard Bethesda Fund. The Fund is a registered charity that mainly provides care to members of Gospel Standard Churches. It is the choice of residents to adhere to certain beliefs and Bethesda House is run in accordance with these. Residents are expected to attend chapel services and to meet together in the lounge for prayer on a daily basis. Bethesda House was purpose built. It has one twin and eleven single rooms on the ground floor. All except one of the rooms have en-suite facilities. Staffing levels are maintained at a minimum of two care staff on duty during the waking day. At night one member of staff undertakes a waking night and another provides sleeping in provision. Catering and housekeeping staff are also deployed. Bethesda House is not registered to provide intermediate or nursing care. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.20am and 12.30pm on the 13th May and 9.40am and 2pm on 24th May 2005. The Inspector undertook a tour of the premises and spoke with six residents and two staff. On the first day of the inspection, the inspector also looked at care planning information, the medication and the fire log book. Miss Wheeler was not on duty during this time and therefore an alternate date of 24th May 2005 was arranged for discussion to take place regarding previous requirements and recommendations. During this time personnel, training and health and safety documentation was viewed. What the service does well: What has improved since the last inspection? What they could do better: Some residents do not feel listened to and there are no formal systems to encourage consultation. Consideration must therefore be given to structures such as residents meetings or individual work with residents. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 6 Further attention must be given to health and safety matters. This must include a review of all information, increased fire safety and awareness within the environment. 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 House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 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 House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 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) 1, 2, 3 and 5 The admission procedure is well managed. Prospective residents are able to make an informed choice about their admission through written information and visits. The home does not offer intermediate care. EVIDENCE: The organisation has recently developed a new Statement of Purpose. The document addresses all homes within organisation. Common themes are initially identified and the document then continues with information about each home. It was suggested that individual documents could be easier to read and find required information. Miss Wheeler however, believed that many residents choose the organisation and then make their decision regarding which home to go to. A global approach is therefore of benefit. A new contract form has been developed. This is detailed and contains the required information. Records of one resident recently admitted to the home from hospital were viewed. These were detailed although completed on the day of admission. This was discussed with Miss Wheeler who reported that the lady was known to the home and had had various respite stays. Miss Wheeler stated that sufficient information was gained in order to assess that her needs Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 9 could be met within the home. Some residents spoken to expressed they wanted a Bethesda home and therefore geographically the decision was made. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 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 and 9 Care planning has recently been significantly improved giving staff adequate information to meet residents’ needs. Health care is well managed and medication, with a number of minor adjustments, ensures a safe system. EVIDENCE: Since the last inspection significant attention has been given to develop careplanning information. All care plans were comprehensive, contained detailed information and were up to date. Some residents were aware that they had a plan of care although were not sure where it was kept. Daily records were also much improved with less subjective language. A separate record of health intervention is maintained. This was detailed, identified a range of services and follow up action. The medication was ordered and all medication administrative sheets were satisfactorily signed. The home maintains a record of receipt and disposal of medication. The medication and homely remedies policies have recently been updated although the homely remedies policy has not as yet been signed by a GP. Some hand written instructions had not been countersigned. Some boxes of medication displayed ‘as directed’ and some names of medication were different on the MAR sheet to those on the box. Miss Wheeler had addressed these matters with the GP and pharmacist. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 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 standard(s) 12, 14 and 15 Residents greatly appreciate the significant commitment given to the spiritual focus of the home. While additional activities appear limited, residents appear content with this. However, further external activities and consultation strategies would be of benefit to some. A varied, well balanced diet is offered. EVIDENCE: All residents reported that the meeting of spiritual need was the most important part of living within the home. Daily prayer meetings were the focus of the day and access to services if unwell was paramount. Some reported great fondness of the preachers and greatly appreciated their time. Residents reported little other activity within the home. For some, with a preference to follow solitary hobbies of reading, this was not a problem. However two residents reported that additional trips out, to town or for a drive around the local villages would be beneficial. Enjoyed trips included the local garden centre. A trip to Westonbirt Arboretum had been arranged. Residents reported they were able to follow their own interests and spend their time in their room if they wished. One resident reported that she joined others in the lounge for the daily service but spent all other times in her room. Another resident felt you could have a lie in yet there was an expectation that you would be in the dining room for breakfast unless unwell. Miss Wheeler was asked to clarify this with residents. As an area of development it was reported that some residents would benefit from greater involvement and discussion about their needs and Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 12 the home. For example the front door being locked, although required, was noted to be a restriction for some and a code lock was suggested as being more appropriate. It was agreed that such matters could be addressed within a setting such as a residents meeting. The home has a rotating menu, which appeared varied and is based on residents’ likes and fresh produce. Residents generally commented very favourably about the food and homemade cake was popular. Some residents felt food would be a useful topic to discuss if a residents meeting was offered. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 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 standard(s) 16 and 18 While residents have access to the home’s complaint procedure, not all feel their concerns would be addressed. Some residents do not feel listened to. Insufficient systems are in place at this time to safeguard residents from abuse. EVIDENCE: All residents have copy of the home’s complaints procedure although it is not visually displayed within the home. Some residents reported that if they had a problem they would tell a member of staff. There was not however total confidence that their issues would be satisfactorily addressed. An element of not being listened to was apparent although as stated earlier in this report, in the event of a residents’ meeting these matters could potentially be resolved. There have been no formal complaints reported to the home or to CSCI. Miss Wheeler reported that she is currently in the process of updating the home’s adult protection policy. However the old procedure, inappropriately referring to in house assessment, remains on the notice board in the office. Some staff have recently undertaken adult protection training. One resident currently has a small amount of money kept for safekeeping within the home. This is managed appropriately with clear records, receipts and two signatures to demonstrate expenditure. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 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 standard(s) 19, 20, 23, 24, 25 and 26 The home is comfortable, clean and furnished to a good standard. Attention to radiators covers has ensured residents’ protection. EVIDENCE: The home was purpose built and all residents’ bedrooms except one, have ensuite facilities. There is a comfortable and well-furnished lounge and a separate dining room. Residents are encouraged to personalise their rooms and are able to have telephone lines if they wish. Televisions are not permitted in private accommodation. Residents reported being totally happy with their rooms although the slope to the communal areas and the distance involved causes difficulties to some. One resident reported Bethesda was a marvellous provision and she wouldn’t want to be anywhere else. The laundry was ordered and clean. All residents reported that the service received was positive although on occasions small items such as handkerchiefs could get lost. Since the last inspection radiator covers have been fitted throughout the home. Hot water temperature controls have also been purchased and a date has been arranged for their fitting. All areas of the home were cleaned to a good Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 15 standard. Miss Wheeler has received a copy of the NHS up to date infection control guidelines. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 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 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, 29 and 30 Staffing levels are being maintained as required by the previous Registration Authority. Miss Wheeler is currently undertaking a high level of care shifts, which restricts time available to residents and management responsibilities. Residents are protected by well-managed recruitment procedures. EVIDENCE: During the waking day there are two care staff on duty. There are also domestic staff and a cook. At night one member of staff undertakes a waking night and another provides sleeping in provision. It was noted from the staffing roster that Miss Wheeler has undertaken a significantly high level of care shifts. This was discussed and Miss Wheeler stated that this has been on a temporary basis and is not a usual occurrence. The personnel files of two new staff were viewed and both contained the required information. Written references and CRB disclosures had been gained and a health declaration formed part of the application form. All prospective staff members are given a job description, a copy of the GSCC code of conduct and a staff handbook. A probationary period of three months is given. Personnel and training records do not currently demonstrate the training that has been undertaken. Miss Wheeler was therefore advised to up date the information and gain certificates to demonstrate training undertaken. At the last inspection a requirement was made to ensure that all staff have dementia care training. Eight staff are currently undertaking this through a distant learning programme. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 17 Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 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) 38 Although radiator covers have been fitted throughout the home, further shortfalls within health and safety place residents at risk. EVIDENCE: As reported upon during the early part of this report, radiator covers have now been fitted throughout the home. Hot water temperature regulators have also been purchased and a date has been arranged to fit them. At the last inspection a requirement was made to ensure that residents were safe guarded from hazardous substances as bathroom cleaner was left on a bath. This remains unchanged. The door to the sluice was also left open giving access to other hazardous materials. The Fire Log Book demonstrated that the visual checks of the means of escape and fire fighting equipment were missed in December 2004 and April 2005. This also applied to the testing of the emergency lights. There were three gaps within fire instruction and a fire drill was not evident within the Jan/March Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 19 period. The fire risk assessment was dated 2003 and therefore in need of updating. A defect noted was not identified when rectified. The home has a range of individual risk assessments, which have been updated within the care planning review. However many environmental risk assessments were originally devised in 2001/2 and have repeatedly had a review date recorded on them. Miss Wheeler was advised that the Health and Safety file as a whole would benefit from review. This should then include clarity to issues raised. For example within the section of kitchen safety it is recorded that staff should receive yearly refreshers. It is not evident whether this is provided. Some documentation refers to waiting for radiator covers, yet these have been fitted. A record of accidents such as falls is maintained although one entry did not detail any injury and another had incorrect dates. Attention is required to ensure all entries are an accurate reflection of the incident. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 3 COMPLAINTS AND PROTECTION 2 3 x x 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x x 1 Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 21 No 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 14 Regulation 12(1)(a) Requirement The Registered Person must ensure that systems to enable greater consultation with residents are developed. This may be in a form of a regular residents meeting. Opportunities should be given to discuss matters such as external activities and routines within the home. The Registered Person must ensure that residents are fully listened to and any complaints are fully investigated and documented within a complaint log. A similar requirement was made at the last inspection. The Registered Person must ensure that the adult protection policy contains details of multiagency working. A copy of the policy must replace the out of date information on the staff notice board. This was identified at the last inspection. The Registered Person must ensure that residents are safeguarded from the risks of hot water by fitting individual temperature controls. This was identified at the last inspection. Timescale for action 31st July 2005 2. 16 22 31st July 2005 3. 18 13(6) 31st July 2005 4. 19 13(4) (a)(c) 31st August 2005 Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 22 5. 19 13(4) (a)(c) 6. 30 18(1)(a) 7. 38 13(4) (a)(b)(c) 8. 38 13(c) 9. 38 23(4) (c)(iv) 23(4) (d)(e) 10. 38 11. 38 12(1)(a) The Registered Person must ensure staff are aware of the difficulties some residents have with the internal slope and give assistance as required. Such difficulties should be recorded within individual plans of care. The Registered person must ensure all training is documented with certificates as appropriate in order to demonstrate training undertaken and any shortfalls. The Registered Person must ensure that all health and safety information, including environmental and fire risk assessments are up dated. The Registered Person must ensure that all substances such as cleaning materials are stored securely. This was identified at the last inspection. The Registered Person must ensure that fire safety systems are tested as required. Such testing must be recorded. The Registered Person must ensure that all staff have fire instruction and a fire drill takes place during each identified period. The Registered Person must ensure that all written accident reports are detailed and accurately reflect the identified incident. 30th June 2005 31st July 2005 31st August 2005 From 24th May 2005 From 24th May 2005 From 24th May 2005 From 24th May 2005 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 9 Good Practice Recommendations The Registered Person should ensure that all written instructions to the medication administration records are D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 23 Bethesda House 2. 3. 9 38 signed by two people. The Registered Person should ensure that a GP signs the homely remedies list. The Registered Person should ensure that any problem identified with the fire safety equioment, is recorded once rectified. Bethesda House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 24 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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 House D51_D01_S28561_BETHESDAHOUSE_V227313_140505_Stage4.doc Version 1.30 Page 25 - 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!