Inspection on 19/04/05 for Bethrey House

This inspection was carried out on 19th April 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 15/08/05

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 Goldthron Hill Penn Wolverhampton WV2 3HR Lead Inspector Ian Harris Unannounced 19 April 2005 08:30 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 V222087 UAI 190405 stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Bethrey House Address 43 Goldthorn Hill, Penn, Wolverhampton, West Midlands, 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) Limited Vacant Care Home 18 Category(ies) of Old age (18) registration, with number of places Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Females aged 60 years and above and males ages 65 years and above. Date of last inspection 9th August 2004 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 V222087 UAI 190405 stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 hours. It was carried out because the home has been without a registered care manager for some time. Two additional visits have been made since the last announced inspection. The fullest co-operation was given by the Acting Care Manager, staff and residents to the Inspection Officer. During the inspection a tour of the premises took place and staff and care records were inspected. 5 of the 17 staff were on duty, and 8 of the 17 residents were spoken to, 5 residents were on holiday. On the day of inspection the home was found to be warm, clean and comfortable. All the residents spoken to that could express themselves in a meaningful way confirmed that they were happy and content. Only positive comments were receive regarding the staff and the care provide by the home. What the service does well: What has improved since the last inspection? 1. 2. 3. 4. 5. The home has improved the case records and care plans. Social and leisure activities. Re-carpeted 3 residents bedrooms. Improved the ventilation in the kitchen Replaced frosted glass in a resident’s bedroom. E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 Page 6 Bethrey House What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full 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 V222087 UAI 190405 stage 4.doc Version 1.20 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 V222087 UAI 190405 stage 4.doc Version 1.20 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) 3 and 5 Both standards have been fully met. The home is following good procedures and practice. EVIDENCE: The home provides very detailed care plans for each resident, which are reviewed on a regular basis. There was a care plan on every resident individual file to show that, where necessary, special services are obtained to met the residents individual needs. All residents are encouraged to visit the home prior to admission. However it was noted that on occasions the visits are declined and relatives visit the home 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 and is discussed with the residents and their relatives at the time of admission Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 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) 7, 8, and 9 All three standards have been fully met EVIDENCE: The home provides a good care plan for each resident based on the initial assessment. The care plans are drawn up by staff with consultation with the resident and their family. There was evidence on file to show that the care plans are reviewed on a monthly basis. The home is well supported by local G. P.’s and all paramedical services. Where possible the residents are encouraged to retain their own G. P.’s, Dentists and Opticians. However if a resident has moved outside of their area, the Care Manager ensures, that these services are provided by local practitioners. Medication is administered by means of a monitored dosage system. The system appears to be working well. The home receives good support from the local pharmacist and the care Staff, are trained in the system before they are allowed to administer medication. The home does have policies and procedures, which are an integral part of the homes staff induction programme. Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 Page 10 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 and 15 Both standards were fully met EVIDENCE: There are a number of residents who go out on a regular basis with relatives. The Care Staff encourage the residents to maintain contact with the local shop and community by arranging shopping trips to the city centre and to the local shops and pub. Information about forthcoming events and activities are displayed on the notice board in the reception area of the home and these are discussed at resident’s meetings. The Acting Care manager and staff have arranged for 5 of the residents to go on a short holiday to Lowestoft. The Acting Care Manager stated that the residents are consulted regarding the day-to-day running of the home through social committee meetings and by feedback from their key-workers. The key-workers also identify interests that the residents wish to pursue. A regular programme of musical evenings, Art and Craft sessions, board- games and sing-a-longs is organised within the home. From the observations made and the comments received from the residents and their relatives confirmed that particular attention is given to the resident’s individual preferences. In regards food, all the comments made by residents Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 Page 11 regarding the quality, quantity and variety of food provided were highly complimentary. Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 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) 18. This standard was fully met. 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 home has a complaints book in which all complaints are recorded. No formal complaint have been received since the last inspection The home has very good policies and procedures regarding the Prevention of Abuse, Restraint, Dealing with Aggressive Behaviour and a Whistle Blowing policy that the staff are aware of. Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 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) 19-26 Limited improvement improvements to the décor have been made and there are areas of the home that will need to be improved in order to provide a comfortable and safe environment. 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 has a good rolling programme of redecoration to maintain a good standard. However it was noted that the first floor corridors are in need of redecoration, the cooker in the kitchen needs repairing or replacing. Also increased ventilation in the kitchen would be an improvement. The home complies with the National Minimum Standards regarding numbers of bathrooms and toilets. It was noted that the floor tiles in the ground floor W.C. are stained and should be replaced and the ground floor bathroom needs refurbishing. It was noted that the thermostatically controlled mixer valve in the shower room on the ground floor is not working and needs replacing. It was also noted that the home has still not been assessed by an Occupational Therapist. Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 Page 14 Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 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) 27-30 All standards were fully met. 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’s, staff are committed to developing their knowledge and skills and have regular opportunities to do so through external and internal training activities. The home has an induction programme and training programme, which includes N.V.Q training. The programme has been designed to meet the National Training Organisations standards. It was noted that the home has achieved 50 N.V.Q. Level 2 trained care staff. The home operates an acceptable procedure and has registered with the Criminal Record Bureau in order to complete the appropriate checks on staff. There was evidence within the home that the checks are being carried out It was noted that the home does not provide afternoon or evening domestic hours, care staff have to cover these duties. It is recommended that an afternoon or evening domestic staff should be provided, which would allow the care staff to concentrate more time to the residents and minimise the dangers of cross infection. Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 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) 32, 33, 35, 37 and 38. All these standards have been fully met. EVIDENCE: From observations made and discussions with residents and staff indicated that the Acting Care Manager is very approachable and operates an open door policy. The staff and residents stated that they are happy to approach the Care Manager with any problems they might have. There was evidence that the staff participate in the homes planning and development. The Acting Care Manager monitors the quality of the service provided through observations, resident’s reviews, staff and residents meetings, staff supervision, and discussions with relatives and questionnaires. However it was noted that the home has not produced an annual development plan based on the findings. All the records and administrative procedures within the home that were inspected were found to be well ordered and well maintained. Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 Page 17 The home has a good health and safety policy and all staff are aware of their responcibilities regarding these issues and a number of staff have received trianing. Fire fighting equipment is well maintained However the systems are not regularly checked. In regards to any accidents, they are all recorded in an appropriate record book Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x 3 x 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 4 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x 3 3 x x x 3 2 Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 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 op22 Regulation 23(2)(a) Requirement The registered person must ensure that the home is assessed by a qualified occupatioal therapist (Previous timescale of (01/10/05) The registered person must repair or replace the cooker in the kitchen (Previous timescale (01/10/04). The registered person must ensure that copies of monthly regulation 26 reports are sent to the commission (Previous timescale (01/10/04). The registered person must ensure that the floor tiles in the ground floor W.C. are replaced.(Previous timescale 01/10/04 The registered person must ensure that the first floor corridor is redecorated. The registered person must ensure that the thermostatically controlled mixer valve on the ground floor shower is repaired or replaced. The registered person must ensure that the weekly tests of the fire prevention equipment takes place and is recorded Timescale for action 01/06/05 2. OP19 23(2) (c ) 01/06/05 3. 26 Schedule 2 OP21 23(2) (b) 01/06/05 4. 01/05/06 5. 6. OP19 OP21 23 (2) (b) 23 (2) (B) 01/08/05 01/06/05 7. OP38 23 (4) 01/05/05 Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 19 27.7 Good Practice Recommendations The registered person referbishes the ground floor bathroom. That the registered person provides afternoon or evening domestic hours. Bethrey House E56 S20882 Bethrey House V222087 UAI 190405 stage 4.doc Version 1.20 Page 21 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 V222087 UAI 190405 stage 4.doc Version 1.20 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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