Inspection on 08/01/09 for Bethesda House

This inspection was carried out on 8th January 2009.

CSCI found this care home to be providing an Adequate service.

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 07/12/06

Bethesda House 08/11/05

Bethesda House 13/05/05

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 18/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Bethesda House Derry Hill Bethesda House Calne Wiltshire SN11 9NN     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Alison Duffy     Date: 2 8 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 37 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 37 Information about the care home Name of care home: Address: Bethesda House Bethesda House Derry Hill Calne Wiltshire SN11 9NN 01249816666 01249758877 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): The Gospel Bethesda Fund Name of registered manager (if applicable) Miss Rebecca Wheeler Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: No more than 1 male service user with physical disability No more than 12 service users over 65 years of age The Registered Person will continue to provide personal care and accommodation to service users, who whilst at the home are diagnosed with Dementia, until such time that their care needs cannot be met. Date of last inspection Brief description of the care home Bethesda House is registered to provide care to thirteen older people, one of whom may have a physical disability. The home is one of a number of homes managed by the Gospel Standard Bethesda Fund. One of the conditions of residency is the continued attendance at a Gospel Standard chapel unless prevented by frailty or illness. In such Care Homes for Older People Page 4 of 37 care home 13 Over 65 12 0 0 1 Brief description of the care home circumstances, services are relayed to the home and people using the service, are able to participate, within the lounge or their own room. Miss Rebecca Wheeler is the registered manager. Bethesda House is a purpose built detached property. It has one twin and eleven single rooms on the ground floor. All except one of the rooms have en-suite facilities. There is a comfortable lounge and separate dining room. Pleasant, well maintained gardens surround the property. 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. Fees for living at the home are from 385.95 - 442.40 a week. This does not include services such as chiropody or hairdressing. Care Homes for Older People Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection took place over three days. The first day took place on the 8th January 2009 between the hours of 9.20am and 2pm. The manager was not available so a second day was arranged. This took place on the 22nd January 2009 between 9.25am and 2.45pm. Feedback was given to Miss Wheeler on the 28th January 2009. The last key inspection of this service took place on the 7th December 2006. We met with people who use the service in their own rooms and within communal areas. We spoke with the staff members on duty. We observed the serving of lunch and toured the accommodation. We looked at care-planning information, training records, staffing rosters and recruitment documentation. Care Homes for Older People Page 6 of 37 As part of the inspection process, we sent surveys to the home for people to complete, if they wanted to. We also sent surveys to be distributed by the home, to peoples care managers, GPs and other health care professionals. The feedback received, is reported upon within this report. We sent Miss Wheeler an Annual Quality Assurance Assessment (AQAA) to complete. Information from the AQAA is detailed within this report. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the care home does well: What has improved since the last inspection? What they could do better: Although care planning is of a satisfactory standard, there are some areas, which would benefit from further detail and clarity. When a district nurse is regularly providing medical support to a person, this should be detailed within the persons care plan. In the event of a wound, the management of the sore, its healing and measures to reduce any further risk of deterioration must be clearly evidenced. Confidential information such as care planning documentation must be securely stored at all times. If a risk, such as losing weight is identified, ways in which the risk is to be managed must be fully documented and implemented. Within risk assessments, the actual risk to the person should be clearly identified, so that adequate control measures can be Care Homes for Older People Page 8 of 37 put in place. A review of procedures must take place to ensure that people are not at risk of a medication error. The current procedure of placing medication within small bottles and giving them to the person to take at the end of their meal, gives potential risk. Staff must ensure that the person has taken their medication before they sign the medication administration record. Any person who is self medicating must be assessed as competent to take this responsibility. Staff should ensure that any handwritten instruction is countersigned and variable doses of medication are clearly stated. While staff training is arranged, the use of more external facilitators would ensure variety and greater specialist knowledge. The environment is generally of a good standard yet consideration should be given to ways in which the bathrooms could be made more homely and inviting. The carpet in one persons room is in need of replacement. While people did not raise staffing levels as an issue, a review of the staffing arrangements at key times of the day should be undertaken. This applies particularly to the evening shift when there are two carers with the added responsibility of preparing and serving tea/supper. To ensure a robust recruitment procedure, all applicants must complete their own application form. They must sign the document to ensure it is an accurate account. A reference from the persons current employer should be gained. The quality assurance system currently used, showed that people were content with every aspect of the service. A review of the format of the questionnaires and other consultation systems may increase the opportunity of more detailed feedback and an involvement in developing the service. An investigation into the recent high level of falls must be undertaken. Control measures to minimise the risk of further incidents must be considered, implemented and regularly monitored. Information regarding the safe use of harmful substances, such as cleaning products must be readily available for staff reference. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A clear, focused admission procedure is in place, which assures an appropriate placement. Evidence: There is a strict admission criterion in place. This is clearly identified at an early stage within the admission process. To be eligible for a placement within the home, the prospective person must be a member of the Gospel Standard Churches or have regularly attended Gospel Standard chapels. People must complete an application form. This is circulated to members of the Bethesda Fund Committee. Identifying the prospective persons church and Minister, form part of the assessment documentation. As part of the process, contact is made with the prospective persons GP. Information about medication and past and present health conditions is requested. Miss Wheeler generally visits people in their home environment to complete an assessment of their health and personal care needs. A decision to offer occupancy is then made, taking Care Homes for Older People Page 11 of 37 Evidence: into account individual need and spiritual aspirations. On the second day of our visit, Miss Wheeler visited a prospective new person to the service, in his/her own home. We looked at the assessment documentation of the person most recently admitted to the home. The information identified details of the persons health and personal care needs, social interests and preferred routines. An assessment, which identified the persons risk of developing a pressure sore, was in place. This gave a number, which identified the level of risk yet there was no written conclusion, as to what this meant in practice. Standard 6 is not applicable to this service, as intermediate care is not provided within the home. Care Homes for Older People Page 12 of 37 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are satisfied with their care yet some additions to care plans would ensure better clarity to the support required. Where a risk is identified, measures to ensure a persons safety must be in place. People have good access to health care personnel. Peoples rights to privacy and respect are maintained yet need to be further promoted within written documentation. Evidence: People told us that they were happy with the care they received. One person said I can do most things for myself but they help me if I need anything. Another person said they come in and help me get dressed and washed. They are very good. Within surveys, people generally told us they received the care they needed and expected. One person said I could do with a little more help with dressing in the morning. We told Miss Wheeler of this. She said she would try to determine the persons details and would address the need. Miss Wheeler told us that she had reviewed all care plans within a new format. We saw Care Homes for Older People Page 13 of 37 Evidence: that the overall care plan was dated at the end of the document. Areas within the care plan were not signed or dated. We said it was therefore not clear when individual aspects, had been reviewed or up dated. During the inspection we saw that the care plans were kept in the dining room. They were within a trolley, which was not locked. This meant there was the possibility of unauthorised access. Miss Wheeler told us that the trolley is usually locked. Care must be taken to ensure this. Within one care plan, there was good detail about the importance to the individual of make up and jewellery. There was clear information about recognising a urinary tract infection. There were areas however, which we recommended should be further clarified. This included assist XX to get out of bed, as required and uses calming technique. The care plan stated that the person could not manage a knife and fork but used a spoon. It was also stated that all meat should be liquidised and the remainder of food finely cut. We observed the person having their lunch. We saw that these measures were not followed in practice. The person on occasions pushed their food off their plate. They asked for staff assistance. This was given but staff did not support the person with their whole meal. Miss Wheeler told us that the person is given a knife and fork to start off with, as their ability fluctuates. She said the person is not fully assisted during a mealtime, as they eat less than when they are managing independently. We advised that this be further monitored and the information within the care plan be updated, as required. Within another care plan, it was identified that the person was prone to constipation. The plan of action stated encourage fluids and a high fibre diet. Takes laxatives. Promote regular toileting. We advised that these statements be further expanded upon to ensure the person is satisfactorily supported. There was a bowel chart in place although it was not clear if the chart had been fully completed. There was no evidence that the information had been evaluated. We recommended that a procedure be in place in the event of constipation being evident. Within the care plan it was stated you will need to motivate XX to do things and encourage XX to rest during the day but to also remain physically active. We recommended that specific information be documented in order to give clear instructions to staff. Another care plan stated promote activity to help keep brain working yet associated interests were stated. We saw that the District Nurse regularly visited one person due to ulcerated legs. There was no information on the persons care plan about this. Miss Wheeler said information was not regularly exchanged from the District Nurses so it was difficult to ascertain the extent of the wound and its management. While acknowledging this, we said there must be sufficient information to enable staff to support the healing process Care Homes for Older People Page 14 of 37 Evidence: and to contribute to minimising the risk of further deterioration. The care plan highlighted that the person was able to stand and walk on most occasions, with prompting. This conflicted to what we saw and what staff told us. At the last inspection, we made a requirement that each person should have his or her risk of developing a pressure sore assessed. This has been addressed. However, we advised the accuracy of assessments be reviewed, as one person was assessed as low risk yet they had a pressure sore. Within the persons daily record, it was stated has 2 small sores and changed dressing on bottom. There was no further information about how the sore areas were being managed. Other tissue viability assessments highlighted that people had special mattresses or cushions for their chairs. There was a record of the monitoring of peoples weight in a separate book. The information was not stated on peoples care plans. Miss Wheeler told us that information was more accessible for staff within a specific book. We saw that four people, including the person as stated above, had recently lost weight. Some people had not been weighed, as they could not balance on the scales. One record stated weigh weekly yet there was no evidence that this had been undertaken. Miss Wheeler told us she was aware of peoples weight loss. However, due to fluctuation and the amount of loss not being significant, she felt there were no areas of concern. Miss Wheeler was advised to monitor this area and inform health care professionals, as appropriate. We spoke in detail about one persons poor appetite and their preferences of food. A number of risk assessments are in place. The risk assessments address tasks such as bathing or showering, using a kettle and eating and drinking. The assessments form a standard format and if a risk has been identified, the topic is ticked. We advised that the specific risks to the person be identified. Control measures to minimise the risk must also be stated. Within surveys, people confirmed that they received the medical care they required. As stated above, there was evidence within daily records that health care professionals regularly visit. There was evidence of people attending the opticians and receiving dentistry. On the day of the inspection, one person was awaiting a GP. One person told us they are very good and call the doctor if you ask them to. Sometimes they think you might need to see someone, so they call them for you. Within a survey, a health care professional told us staff always ask for advice and act upon peoples health care needs. Medication is stored in a locked trolley and a locked cupboard. Both are securely attached to the wall. We advised that Miss Wheeler ensures the controlled drugs cupboard complies with current legislation (The Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007.) Staff administer all medication from Care Homes for Older People Page 15 of 37 Evidence: original packaging. We saw that they placed the medication into small bottles. These were given to people so that the medication could be taken after the persons meal. We were concerned that the bottles were placed on the table within reach of others. Staff did not watch people take their medication. This meant that they signed the medication administration record without being clear that the medication had been taken. We said this system gave opportunity for error and should be reviewed. The medication administration record of one person was not signed. Staff told us that this person managed their own medication. We said this must be stated and a risk assessment, be in place. Another medication had not been signed, as given. Staff were not aware of why this was so. On the second day of the inspection, the medication had been removed. Miss Wheeler told us that the pharmacy had repeated the instruction but the medication had been discontinued. Within a variable dose of medication, staff had not always identified whether one or two tablets had been administered. Not all handwritten instructions had been countersigned. We saw that all medication had been satisfactorily receipted on arrival into the home. In the event of a person going on holiday, there should be a record that the person has taken their medication with them. This would ensure a clear audit trail of medication. Miss Wheeler told us that all staff receive training before they administer medication to people. Miss Wheeler currently facilitates the training although arrangements are being made for the pharmacy to undertake a formal session. Within the AQAA, it states that over the next twelve months there are plans for more staff to complete accredited medication training. There is a homely remedy policy in place. This was dated 2006 and would therefore benefit from review. Within a persons room we saw two bottles of scalp lotion, which were out of date. There were also two creams, which involved invasive procedures when administering. The creams were not detailed on the persons care plan. Miss Wheeler told us that the creams were not used although needed to be in place to give confidence to the person and their family. There was evidence to suggest that peoples rights to privacy, dignity and respect were promoted. All personal care was provided in private. We saw one member of staff support a person to the toilet. We heard them ask the person if they wanted to be accompanied or if they were happy to ring the bell for assistance. The staff member supported the person, gave privacy and returned in a timely fashion. We saw that staff knocked on peoples doors and waited to be asked in before entering. We recommended that consideration should be given to some terminology within written documentation. Aspects, which did not promote peoples rights to respect, included a bit confused today, behaviour has been a bit difficult and has developed some anti social behaviours. One entry within a daily record stated first call! Slept well all night (not surprising after last night 12 calls.) Miss Wheeler told us that she had addressed the use of the exclamation mark with staff. Care Homes for Older People Page 16 of 37 Evidence: Within a survey, a health care professional told us that staff usually respect peoples privacy and dignity. Care Homes for Older People Page 17 of 37 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Significant consideration is given to meeting peoples spiritual needs, therefore enhancing quality of life for individuals. Some people may benefit from the development of other social activity provision. Visitors are encouraged and important relationships promoted. Meal provision is based on traditional food and is generally enjoyed by people. Evidence: The home continues to give significant consideration to peoples’ spiritual needs. People attend a local Gospel Standard chapel on Sundays and during the week. Morning prayer is undertaken in the home on a daily basis. All people using the service and staff are expected to attend. People using the service who are male, are able to undertake readings, if they wish. Alternatively, visiting ministers or male members of the Gospel Standard Churches conduct the services. If people are not well enough to attend, they are able to listen via the relay system in their room. All chapel services are also relayed to the home. People told us that the focus on their faith was essential to their daily lives. One person commented upon ‘peace, contentment and fulfilment.’ Another person said ‘I just get so much from the services and am thankful for this Care Homes for Older People Page 18 of 37 Evidence: focus.’ Within a survey, a staff member told us ‘all our service users are strict Baptist so all their beliefs are respected and supported.’ The AQAA states, under the heading, what the home does well ‘provides individualised quality care for residents to match their desire for a spiritual and biblical lifestyle.’ People told us that they were happy with spending time in their own room and at times, within the communal lounge. One person told us ‘there is no pressure to socialise if you do not want to.’ They said they liked reading and enjoyed quiet times of reflection. Another person said ‘I like looking out into the garden. We have a wonderful gardener. There’s not much else to do. We have a craft morning but that’s only once a month.’ Another person said ‘we have a craft morning once a month on a Tuesday. Not much else.’ Within a survey, one person using the service told us ‘the home is well run, clean, good food. Would just like a little more occupational therapy sometimes.’ Miss Wheeler told us that she is currently looking into the availability of volunteers, in order to enable more social opportunities for people. Within the AQAA we saw that the development of activity provision including outings was being considered. We heard a member of staff tell a person that they would refill their bird feeder, at the end of their shift. We saw from the person’s care plan that watching the birds was important to them. We saw one person looking at their Christmas cards, as a means of gauging self worth. One person told us about a trip to a local garden centre, which had taken place before Christmas. They said ‘its nice to get out and about and have a change of scenery.’ Other comments were ‘I haven’t been out for a while but then it hasn’t been the weather. I’ll try to go out in the garden when the weather gets better’ and ‘they go out but I don’t want to. I get lots of visitors.’ We saw that two people regularly go out independently without staff support. We advised that a risk assessment and procedures in the event of the person not returning, be developed. We saw that staff had worked well with a person newly admitted, in order to orientate them to the local area. Within care plans, we saw that people were able to undertake small housekeeping tasks such as dusting and their laundry. The home does not permit televisions within the home. Radios and other forms of personal entertainment equipment are permitted in peoples’ bedrooms but not in any of the communal areas. There are also restricted times for their use. This restriction is identified within the home’s Statement of Purpose. People told us they could have visitors, when required. At the last inspection we noted that visitors were discouraged on a Sunday. This was because of chapel services and Care Homes for Older People Page 19 of 37 Evidence: required rests in between. One person told us that they believed this ‘rule’ had been relaxed and people could now visit at any time. Within a survey, under the heading what the service does well, a staff member said gives service users choice in all aspects, very flexible. Good relationships with service users and staff. People told us that they could follow their preferred routines yet one person said they don’t like you staying in bed. Another person said they like you to be up for breakfast. They do not like you to stay in your nightclothes. Miss Wheeler told us that people are encouraged to get up, if staying in bed is to the detriment of their health. Likewise, if a person wishes to eat in the dining room, there is an expectation that they will be dressed. Another person said they say its good for you to keep moving. They like you to walk. Its not easy and its a long way, but I get there. Miss Wheeler confirmed that people are encouraged to keep mobile although staff are responsive to the level of reasonable mobility, people are expected to achieve. One person told us its good, as you can do what you like. You can go to friends or go away when you like. People were generally positive about the meals provided. Specific comments included yes its good, the foods always very good and tasty. I look forward to my lunch and good and wholesome but nothing exciting or imaginative. One person said its nothing exceptional. As stated earlier in this report, one person told us that they had lost their appetite. Staff could not think of any items, which might tempt the person to eat. Within a survey, one person said excellent cooking. Good homely meals every day. The people who completed their survey said they usually or sometimes enjoyed the meals. We saw from the menus that traditional food is provided. There is no choice of meal although people did not raise this as an issue. One person said its not a problem. They know what we like, so wouldnt give us anything we couldnt eat. Miss Wheeler told us the option of a choice of meal is being investigated. The cook told us that she aims to cook all meals from fresh ingredients. She said more fresh fruit and smoothies have been introduced. The cook told us that Miss Wheeler devises the menus. Miss Wheeler told us that the menus are in the process of being reviewed. She said peoples views are being explored. Within the AQAA, it stated that the tea and pudding menu have been reviewed to reduce the amount of carbohydrate and saturated fat and to increase protein and fruit content. There was a menu board on the wall in the dining room. This showed chicken with sauce, fruit blancmange, bake beans. As a means to make the information clearer to people, greater clarity may be of benefit. People told us that they were able to have meals in their room although it was preferred, if they used the dining room. Miss Wheeler told us that people are encouraged to use meal times, as a social experience although are able to eat in their room, if they wish. Care Homes for Older People Page 20 of 37 Care Homes for Older People Page 21 of 37 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Using a proactive approach and encouraging concerns on an informal basis would enable a more positive approach to complaints. Systems to safeguard people are in place yet greater awareness of staff in terms of safeguarding procedures would ensure further protection. Evidence: People told us that they were aware of how to make a complaint. One person said it depends what it is. If it were something trivial, I would speak to a member of staff. If it were more serious, I would go to the office and see Rebecca [the manager.] Another person said If I needed to, I would mention anything I was not happy about to the staff. They are all very good so I know they would sort things out for me. Another person said I would weigh everything up before raising anything. They did not expand upon this view. A member of staff told us that they would speak to Rebecca if a complaint was made. Miss Wheeler told us that there had been no formal complaints. She told us about a person who spoke to her recently about an issue they were not happy with. Miss Wheeler told us that she had encouraged them to make a formal complaint. This was so it could be formally addressed. The person did not want to do this. We discussed the opportunities of addressing matters on an informal day-to-day basis, without the formality of needing to put matters in writing. We suggested that staff could resolve Care Homes for Older People Page 22 of 37 Evidence: the identifying matter by talking to the person and agreeing a solution. With proactive intervention, the issue causing the person discontentment, would be removed. At the last inspection, we made a requirement that all staff must have training in adult protection. The staff training matrix demonstrated that training had been completed. Staff confirmed this. Miss Wheeler told us that she had facilitated the training with the use of a DVD. We asked staff a hypothetical question about what they would do if they were told of an alleged incident of abuse. They told us that they would speak to Rebecca. We advised that further training, which took into account Wiltshire and Swindon safeguarding procedures, should be considered. Miss Wheeler told us that staff had received a copy of No Secrets. This details local safeguarding procedures in the event of a suspicion or allegation of abuse. Miss Wheeler told us that safeguarding is also discussed within staff meetings. Care Homes for Older People Page 23 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is comfortable, homely, clean and generally of a good standard. People are able to personalise their room. Evidence: Each person has a single room on the ground floor, with an en-suite facility. The rooms we saw were pleasant, homely and comfortable. All were personalised with peoples own furniture and possessions. One room had had a new carpet and due to the comfortable armchairs, a sitting room feel had been created. One person said they liked their room, as it was very light and had a good view of the garden. Another person said it’s small but its lovely. Im very comfortable here. Within one room, the carpet near the window was very frayed. The area near the door was stained. Miss Wheeler said she was aware of this yet believed that replacing the carpet would be a challenge. She said the furniture had been bolted to the walls so would not be easy to remove. We advised that this be considered, as the carpet was in need of replacement. We saw the persons spectacles were in the room. The care plan identified that the person needed to wear these for their meals. They did not do so, during the inspection. Miss Wheeler told us that the person often refuses to wear their spectacles, which is why they were in the room. Care Homes for Older People Page 24 of 37 Evidence: Within one room there was an electrical extension socket. We advised that this was a fire hazard and should be replaced. People had their call bells within easy access to them. One person said they had two call bells in different positions, which made them feel safe. Within a survey, one person using the service told us excellent cleanliness at all times. We saw that the rooms, bathrooms and toilets were cleaned to a good standard. Pump action soap dispensers and paper towels were in use in all communal toilets and bathrooms. The bath side in the bathroom at the bottom of the corridor had been removed because of a leak. Miss Wheeler told us that arrangements had been made for the bath side to be replaced. There were commode chairs stored in the bathroom. One was of a wooden frame and difficult to keep clean. It had brown particles in the commode pot. The bathrooms were functional yet not homely or welcoming. Miss Wheeler agreed that the rooms were showing their age and could do with brightening up yet budgetary constraints were an issue. Within one room, there was signage to inform the person of the day of the week. It had not been changed, as it was showing the previous day. Another room had a clock, which showed the wrong date. Miss Wheeler told us that the person did not have the instructions for the clock, so the date could not be changed. It is stated within the AQAA, that new lighting had been fitted to the lounge, main corridor, en-suite facilities and the entrance areas to peoples rooms. People told us that they were satisfied with the laundry service currently in place. One person said my clothes come back quickly and perfectly ironed. I have never had anything ruined. Another person said it’s very quick. A good service. The girls are very good. We saw that the laundry was ordered. We did not review the laundry procedures on this occasion. Care Homes for Older People Page 25 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels, although operating at agreed levels with previous regulatory authorities, require review to ensure individual needs are being met at key times of the day. Prospective staff members must take responsibility of their application to ensure a robust recruitment procedure. External trainers should be considered to facilitate further developments of the staff team. Evidence: Miss Wheeler told us that the home is fully staffed. There are two staff on duty throughout the waking day. Miss Wheeler is also available to give assistance, as required. At night there is one member of staff who undertakes a waking night. A member of staff also provides sleeping in provision. During the morning, in addition to the care staff, there are two housekeeping staff and a cook. This is except on a Sunday, when there are two care staff. Within a survey, a staff member told us we have a good team. There are two cleaners and a cook who all muck in with the carers. We do not have a thats not my job workplace. Brilliant teamwork. We saw from the staffing roster that in the evening, the two care staff prepare and serve the evening meal. Staff told us that this was generally satisfactory although Care Homes for Older People Page 26 of 37 Evidence: proved a challenge, if people were unwell. Within a survey, as a means to improve the service, one member of staff said spend more one to one time with service users but sometimes this is not easy because of being busy. This depends on health etc on a daily basis of the service user, but we do try. We advised that staffing levels, particularly at busy times of the day, be reviewed. People told us that staff responded to their call bell quickly when called. One person said they always come very quickly. Another person said they are all very good. Even when they are busy, they come quickly with a smile. We heard one person ring their call bell for assistance. As people told us, we saw staff respond without delay. We saw that staff have regular handovers to ensure they are fully informed of peoples needs. Each person using the service was mentioned within the handover we observed. Within a survey, a member of staff told us more staff meetings would be of benefit. Staff told us that many training courses are provided. One staff member told us they had recently completed first aid, communication, diabetic care, manual handling and food and nutrition. Within a survey, a staff member told us we have training relevant to our role. NVQ 2 [National Vocational Qualification] very useful. Feel much more confident about job role. Recently did course on communication, which was very good. Within the AQAA, it stated that 77.7 of staff have NVQ level 2. 37.5 have NVQ level 3. These levels indicate that staff have the knowledge and skills to support people. However, due to the level of falls, people may not be in safe hands at all times. A staff training matrix was in place. This demonstrated that varied courses had taken place. We saw that three staff had recently completed a dementia care course at Swindon College. Other staff completed their training in dementia care in 2005. We advised for refresher training to be arranged. Ten staff have recently undertaken an End of Life course at a local hospice. Miss Wheeler told us that she facilitates the majority of the staff training sessions. This has recently included the Mental Capacity Act, nutrition, oral health, abuse, diabetes and food hygiene. Miss Wheeler told us that a DVD is awaited regarding infection control training. In addition to the DVD, Miss Wheeler said she takes information from the Internet. Miss Wheeler said she does not provide training in specialist areas such as first aid. She said an external facilitator would be sourced for these sessions. We advised that further external facilitators be used in order to provide variety and specific expertise. We looked at the recruitment documentation of five members of staff. We noted that within the application forms, the handwriting of the prospective member of staff varied within the document. One application stated likes people. We asked Miss Wheeler Care Homes for Older People Page 27 of 37 Evidence: about this. She told us that she often completes the application form with people, during their interview. She said she often finds that when sending an application form out to people, it is never returned. Miss Wheeler believed that writing the information on the application form during the interview ensures that the required details are captured. We advised that this practice be stopped with the prospective member of staff completing their own application form, before their interview. Each file contained two written references. One reference was not from the persons present employer. Another gave conflicting details about their workplace on their application form and a reference. Not all interview formats had been completed. One medical questionnaire highlighted a health condition, which was relevant to the role the person had applied for. There was no evidence that this had been further explored. There was evidence that a Criminal Records Bureau check (CRB) had been undertaken. A POVAFirst check had also been undertaken yet these details were stored electronically rather than in paper format. Both checks confirmed that the individuals were suitable to work with vulnerable people. Care Homes for Older People Page 28 of 37 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is orderly managed yet greater consideration should be given to ways in which peoples views can be gained. The safekeeping of peoples personal monies is well managed. Systems are in place to promote people’s health and welfare yet greater focus in relation to the management of falls would reduce the risk of harm. Evidence: Miss Wheeler has been the registered manager of Bethesda since 1995. Miss Wheeler qualified as a nurse from the University of Surrey in 1992 and has since completed the NVQ level 4 in Management. Miss Wheeler is also an NVQ assessor. Miss Wheeler has experience of working in rehabilitation, long-term and terminal care and continues to undertake regular training to maintain her professional qualification. Miss Wheeler although well qualified, does not have the Registered Managers Award. At the last inspection, we asked Miss Wheeler to review her qualifications in line with the required criteria to be a registered manager. Miss Wheeler told us that she had viewed our guidance and had contacted various training providers. She believed that she has the Care Homes for Older People Page 29 of 37 Evidence: necessary credentials and does not need to complete any further professional qualifications. While acknowledging Miss Wheelers nursing qualification, we advised her to ensure she does not perform any nursing tasks or diagnostic measures. For example, within daily records we saw a person was raising concern about pain in their foot. Miss Wheeler had recorded most likely to be arterial insufficiency and clogged arteries. I havent told XX this to reduce his/her anxiety. A medical diagnosis from an external source must be sought. At the last inspection, Miss Wheeler was undertaking shifts, as part of the working roster. We made a recommendation that she should be supernumerary to enable her to fulfil her management responsibilities. The staffing roster gave evidence that Miss Wheeler only now covers the working roster at times of sickness or annual leave. Miss Wheeler told us that she has recently sent out quality questionnaires to people using the service. We saw a summary of the feedback and noted that all aspects were positive. There were no suggestions about ways in which to develop the service. People expressed full contentment in every area. While acknowledging this may be an accurate reflection of peoples opinions, we advised that a review of the questions and format of the questionnaires might be beneficial to gain further views. We also advised that regular audits of the home should be undertaken. These should be used alongside the questionnaires, as a means to enable on going development of the service. We advised that such developments should be evidenced within a specific action plan. Within a survey, as a means to improve the service, a member of staff told us encourage more input of service users opinions. At the last inspection, we made a recommendation to consider the implementation of residents meetings. This has not been addressed. One person told us we have had the occasional meeting years ago but nothing like that now. The person told us that they felt meetings might be useful yet they felt too old to be involved. Another person told us don’t really ask you about anything. Its not a problem, as I haven’t got the energy to do anything really. People are encouraged to manage their own financial affairs for as long as they are able. Some have given the responsibility to family members or other representatives. Two people hold money in the homes safe for safekeeping. We saw that the balance sheets, which showed expenditures, identified two staff signatures, as a safeguard to minimise financial abuse. Receipts demonstrated most expenditure. One person had bought items from the homes shop/trolley. Miss Wheeler told us that this expenditure would show on the shops record of sales. Care Homes for Older People Page 30 of 37 Evidence: The environment is well maintained with a focus of peoples heath and safety. Radiators have been fitted with covers. All hot water outlets have regulators to ensure people are not scalded through excessive hot water temperatures. Miss Wheeler monitors the temperatures on a regular basis. She ticks each outlet temperature on a chart to show it is below the recommended 43C. We recommended that the actual temperature be recorded for monitoring purposes. Portable electrical appliances had recently been tested. The fire log book demonstrated satisfactory fire safety systems. The fire alarms and the fire extinguishers had been tested and serviced, as required. Staff had received fire instruction and regular fire drills had taken place. We advised that the specific time of the drill be recorded for monitoring purposes. Documentation about the chemical substances (COSHH) used within the home, could not be located. Miss Wheeler believed staff could have taken the documentation to use, for their NVQ award. Miss Wheeler told us she would renew the information. All such substances were securely stored. Staff have received manual handling training yet we saw two members of staff use an unsafe technique, when moving one person. Miss Wheeler told us that she had reminded staff about this on many occasions. Miss Wheeler said she would ensure further training for staff. Within the accident records we saw that there had been a high level of falls within recent months. Between October 2008 and the present day, there were twenty documented falls. The accident records showed that many of the falls were unwitnessed. One person fell whilst being assisted from their commode to a wheelchair. Some entries stated found on floor. We advised greater detail within the accident records. We also advised that the level of falls be investigated in order to identify any possible trends or triggers. Miss Wheeler told us that peoples frailty had recently increased. While acknowledging this, measures to minimise the risks of falling, must be in place. Care Homes for Older People Page 31 of 37 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 A documented risk 30/03/2009 assessment must be in place for people who go out on their own, without staff support. A procedure to follow if the person does not return, as expected, must be in place. So that the persons health and welfare is safeguarded. 2 7 17 All care plans must be stored securely. So that access to confidential information is restricted. 28/02/2009 3 8 12 Where a risk of dehydration or malnutrition is identified, clear control measures to minimise the risk, must be in place and be regularly monitored and evaluated. So that that the persons health and well being is maintained. 28/02/2009 Care Homes for Older People Page 33 of 37 4 9 13 Staff must ensure that all medication is given directly to the person. They must ensure the medication has been taken before they sign the medication administration record. So that the risk of error is minimised. 28/02/2009 5 9 12 A documented risk 30/03/2009 assessment must be in place regarding a persons ability to manage their own medication, if they wish to do this. The assessment must be kept under regular review. So that the person is able to manage their medication safely. 6 29 19 All applicants applying for a position in the home must compete their own application form and sign the document accordingly. To ensure a robust recruitment procedure, which safeguards people. 28/02/2009 7 38 13 Documentation regarding 30/03/2009 the control of substances hazardous to health must be available for staff reference. So that the health and welfare of people through the appropriate usage and storage of harmful substances is maintained. 8 38 13 An investigation into the high number of recent falls 30/03/2009 Care Homes for Older People Page 34 of 37 must be undertaken. Control measures to minimise the risk of further incidents must be considered and implemented. So that peoples safety and welfare are promoted and maintained. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 When people are unable to be involved in the development of their care plan, an advocate should be involved and evidenced. Identified control measures, to minimise any potential risk to a person should be clearly stated within documentation. Greater clarity within care planning information, should be given to some terms, such as needs assistance. Consideration should be given to purchasing sit on scales so each person can be regularly weighed. Another member of staff should countersign any hand written instruction on the medication administration record. When a person goes on holiday and takes their medication with them, a record of this should be maintained. The person and the staff member involved should sign the record. Where there is a variable dose of medication, the amount administered to the person, should be documented. A review of the homely remedies policy should take place. Consideration should be given as to how social activity provision could be further developed. A record should be maintained of all suggestions and concerns. Consideration should be given to strategies of managing concerns informally rather than encouraging people to formally express their views. 2 3 4 5 6 7 7 8 9 9 7 8 9 10 11 9 9 12 16 16 Care Homes for Older People Page 35 of 37 12 13 14 15 16 17 19 19 27 29 30 33 Consideration should be given to how the bathrooms could be made more homely and inviting. The carpet in the identified bedroom should be replaced. A review of staffing levels with particular attention to the key times of the day, should take place. Within the recruitment procedure, a reference from the applicants current employer should be gained. Consideration should be given to more external training provision. Consideration should be given to the format of the questionnaires and other strategies in order to gain more feedback from people about their views on the service they receive. The actual temperature of the hot water should be documented when monitoring all hot water outlets. Staff should ensure that they record sufficient detail about an incident when making an entry in the accident book. 18 19 38 38 Care Homes for Older People Page 36 of 37 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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