Inspection on 15/08/05 for Bethrey House

This inspection was carried out on 15th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bethrey House 05/08/08

Bethrey House 08/08/07

Bethrey House 06/02/07

Bethrey House 19/10/06

Bethrey House 19/04/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bethrey House 43 Goldthorn Hill Penn Wolverhampton WV2 3HR Lead Inspector Ian Harris Announced 15 August 2005 08.00 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. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bethrey House Address 43 Goldthorn Hill, Penn, Wolverhampton, WV2 3HR 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) 01902 338213 01902 338213 Quality Homes (UK) Ltd Susan Minshall Older People 18 Category(ies) of Old Age (18) registration, with number of places Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) Females aged 60 years and above and males aged 65 years and above. Date of last inspection 19.04.05 Brief Description of the Service: Bethrey house was built as a detached private dwelling around the turn of the century. It was first registered as a residential care home in 1981. Since then, the home has undergone a number of extensions and alterations. The home now provides accommodation for 18 older people. There is a car park at the front of the property and a patio and garden at the rear. The home is situated approximately two miles from Wolverhampton city centre and is on a main bus route to the city centre. There are local shops and amenities less than a quarter of a mile from the home Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over 5 hours. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report. The fullest co-operation was given to the inspection officer by the Care Manager, staff and residents. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 4 of the 14 care staff were on duty, and 8 of the 17 residents were spoken to. On the day of inspection the atmosphere within the home was found to be warm, friendly, comfortable and safe with contented residents. Six relatives comment cards and Severn residents comment cards were returned all with favourable comments regarding the care provided by the home. What the service does well: Bethrey House continues to provide a good standard of care for the residents. The Care Manager and staff are to be commended on their efforts to encourage the residents to maintain their independence through social activities both within and outside the home. In particular the work by the staff in arranging and taking residents on holiday is to be commended. Observations during the inspection saw very attentive staff providing for the individual needs of the residents. A number of residents and relatives confirmed the care staff are very supportive and caring. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 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. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 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 Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 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) 4 and 5 The home provides clear and accurate information to prospective residents on the services provided, enabling them to make a properly informed choice about the home. All residents are given a written contract on admission to the home. EVIDENCE: Each resident is provided with a detailed service users guide and statement of terms and conditions when they move into the home. This statement contains all the required information. The statement is clear on what the fees do and do not cover. Residents are encouraged to visit the home prior to admission. An introductory visit is always offered to prospective residents, on some occasions the visits are declined and relatives visit on behalf of the prospective resident prior to admission. A trial period is included in the statement of terms and conditions of residence and the homes contracts. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 9 and 11 The systems for the administration of medication are good with clear and comprehensive recording arrangements in place to ensure resident’s medication needs are met. Staff are sensitive to the individual needs of each resident in the terminal stages of life and meet these in a professional manner EVIDENCE: Medication is administered by means of a monitored dosage system. The system appears to be working very well. The home receives good support from the local pharmacist. All Care Staff have been trained to use the system before they are allowed to administer medication. The home has very good policies and procedures, which are an integral part of the staff induction programme. Residents’ wishes with regard to terminal care and arrangements after death are obtained at the assessment stage, if possible. Family members are involved in these discussions if appropriate. Unless there are medical reasons for not doing so, service users are able to spend their final days in their own rooms. Where the needs of service users change, re-assessments are requested. The home has clear policies with regard to dying and death. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 10 The Care Manager and Care Staff are conscious of the need to provide extra support to the residents in their final days at the home. All the Staff are very aware of the need to be particularly sensitive, caring and attentive to the residents needs prior to their death. The care manager is also aware of the support the staff should provide to relatives and colleagues. Resident’s relatives are encouraged to be fully involved in the residents care at this particular time. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 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) 13, 14 and 15 Staff work in close liaison with residents and their relatives to understand their individual lifestyles and preferences in order that these can be continued when they move the home. Individuals are enabled to exercise choice and control over their lives wherever possible balancing the rights and risks with each individual The meals in the home are good homely type offering both choice and variety and also catering for special dietary needs. EVIDENCE: The staff at the home encourage regular contact between residents and their relatives by inviting them to parties, fetes and celebrations. It was noted that approximately 6 residents are regularly taken out by their relatives. The residents and staff stated that the residents are consulted regarding the day-to-day running of the home through residents meetings and by feedback from their key-workers. The key-workers also identify interests that the residents wish to pursue The observations made, examination of menus and the comments received from the residents and their relatives confirmed that particular attention is given to the residents’ individual preferences. Comments made by residents regarding the quality, quantity and variety of food provided were highly complimentary. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 17 The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon All residents are assisted to exercise their legal rights, either by family, staff or where appropriate by an advocate provided by Care Aware. EVIDENCE: The home has a comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence the service users guide and copies are also placed on the notice board in the hall. The home has a complaints file in which all complaints are recorded. It was noted that no formal complaints have been received since the last inspection and all minor complaints are dealt with appropriately and quickly. Residents are assisted to exercise their legal rights, either by family, or staff. All permanent residents are registered on the electoral register to vote. They may vote if they wish either by post, or they are assisted to go to the polling station if this is requested and most residents voted in the last general election. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The standard of the environment within the home and the garden is good providing the residents with an attractive, comfortable, homely and safe place to live. EVIDENCE: The home has been established for a number of years and has undergone alterations in order to provide appropriate accommodation for 18 older people. The home is maintained to a good standard as is the gardens and grounds and provides a comfortable homely and safe atmosphere. It was noted that 5 residents’ bedrooms, kitchen, all the corridors have been redecorated. The ground floor bathroom and toilet have new floor covering. Also a new cooker has been provided. However it was noted that the shower room on the ground floor is still not working and must be repaired. It was found that the staff room is being used as a storeroom. This must be cleared and returned to it’s original use. The home has good hygiene and infection control policies and all the care and catering staff Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 14 have undergone Food Hygiene training .The domestic staff have undergone C.O.S.H.H. training. All staff are conscious of the risks of cross infection. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 15 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 and 29 The home is well staffed with adequate numbers and skill mix. The home operates an efficient recruitment procedure. EVIDENCE: The inspection of staff rotas and discussions with staff indicated that the home is well staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. The home operates an efficient recruitment procedure and has registered with the West Midlands Homes Association in order to complete the appropriate checks on staff. There was evidence within the home that all the checks are being carried out. However it was noted that not all the staff files have a current photograph or a copy of birth certificate. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 16 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) 33, 34, 35 and 36 The home is well managed, where service users interests and welfare are well processed and promoted. The systems for resident consultation are good with evidence suggesting that their views are sought and acted upon Residents finances are being handled appropriately by designated senior staff. EVIDENCE: The routines and activities within the home are flexible and built around the needs of the residents. There was also evidence to show that staff consult with the residents regarding the choice of meals and activities within the home. There are regular residents meetings where residents are consulted about menus and entertainment etc. Also the Key-Worker system in operation is designed to ensure residents’ wishes are responded to. All the Financial records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 17 It was noted that the home has a good formal supervision system in place however supervision meetings are not is taking place on a regular basis. Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 18 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 x x x 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x x 3 3 3 2 x x Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 19 YES 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 OP 19 Regulation 23 (2) (b) Requirement Timescale for action 01/10/05 2. OP 19 23 (3) i, ii. Schedule 2 18 (2) 3. OP 29 4. OP 36 The registered person must ensure that the thermostatically controled mixer valve on the ground floor shower is repaired or replaced (Previous timescale 01/06/05 The registered person must 01/10/05 ensure that the staff room is cleared and returned to its original use. The registered person must 01/10/05 ensure that a current photograph and a copy of the birth certificate are placed on all staff files. The registered person must 01/10/05 ensure that all staff receive formal supervision at least 6 times a year. 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 Good Practice Recommendations Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 2nd Floor, St Davids Court Union Street Wolverhampton WV1 3JE 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 Bethrey House E56 S20882 Bethrey House V235337 AI 150805 stage 4.doc Version 1.40 Page 21 - 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. 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