Inspection on 05/08/08 for Bethrey House

This inspection was carried out on 5th August 2008.

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

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 08/08/07

Bethrey House 06/02/07

Bethrey House 19/10/06

Bethrey House 15/08/05

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Bethrey House Bethrey House 43 Goldthorn Hill Penn Wolverhampton West Midlands WV2 3HR Lead Inspector Bhag Jassal Unannounced Inspection 5th August 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bethrey House Address Bethrey House 43 Goldthorn Hill Penn Wolverhampton West Midlands WV2 3HR 01902 338213 F/P 01902 338213 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Quality Homes (UK) Limited Helen Kathleen Sims Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (19) of places Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only to service users of the following gender: either whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category OP 19 Dementia DE 19 The maximum number of service users to be accommodated is 19. 2. Date of last inspection 8th August 2007 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 and personal care for 19 older people with Dementia care needs. 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. Weekly fees range from £357.00 - £ 408.00. Information of the home and the provision of the service are available in the statement of purpose and service users’ guide. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means the people who use the service experience Adequate quality outcomes. This report is on a Key Inspection, part of which included an unannounced visit undertaken on 5th August 2008. This unannounced visit started at 09:00 and lasted 10 hours and 10 minutes. The home had 19 places occupied. The judgements made within this report are based upon information supplied by the home, from interviews with the Care Manager, the staff and people who use the service and their relatives. During the course of inspection the assessment information and care plans were inspected for 4 people who use the service. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken and observation of care practices and interaction between staff and people using the service was also completed. We looked at 4 files of people who use the service to enable us to monitor progress in meeting previous requirements. Discussions took place with several members of staff and several people who use the service and four visiting relatives were spoken to throughout the day of inspection. Care Manager – Ms Helen Sims was present throughout the inspection process. The Registered Provider - Dr Sadhu Singh Gakhal was also present for a very brief period in the afternoon. On this occasion all the key Standards of the National Minimum Standards were inspected. Regulation 37 Notifications, concerns and complaints against the home, Regulation 26 reports and Annual Quality Assurance Assessment (AQAA) received from the care home were also considered and discussed with the Care Manager. We wish to thank the Care Manager, Responsible Individual, the staff, people who use the service and their relatives for their assistance and co-operation on the day of inspection. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The Care Manager has introduced formal supervision for staff, a new training programme and the key worker system of working. Medication practices have improved and more staff have received training in safe handling of medicines. A number of staff have completed their training in infection control, Dementia care, NVQ Level 2, adult protection and food hygiene, and this will enable them to expand their knowledge and skills and enhance the care they give to the people who use the service. It was noticeable that there have been many improvements made to the environment of the home. A rolling programme of decoration and Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 7 refurbishment has been implemented, and some of the communal areas and bedrooms have been redecorated and new floor covering and some items of furniture have been provided. What they could do better: The home must continue to update the needs assessments, risk assessments and care plans of people who use the service and these should be kept under regular review. The home must also continue to improve the detail and quality of daily care recordings. This is to ensure that each person’s care needs are known and the actions necessary to meet them are understood by everyone. Those members of staff who as yet have not received mandatory training in safe working practice topics – for example, first–aid, food hygiene, health and safety, fire safety, infection control, moving and handling, adult protection, Dementia care, safe handling of medication, and NVQ Level 2 must do so as a matter of priority. This training would enable staff to improve further their care practices, social care knowledge and skills. Formal induction training programme for new members of staff should be implemented in accordance with the Skills for Care requirements and standards. The introduction of a structured programme of social and leisure activities provided after consultation with people who use the service would really improve the quality of life and help maintain their links with the local community. Staffing levels needs to be maintained in sufficient numbers at all times to ensure that all care needs of people living at Bethrey House are fully met. One on-site survey completed by a member of staff stated that “We could offer services to meet the needs of different cultures and religions. We have been very short staffed, which is a problem as it makes it difficult to meet the needs of individuals. The facilities are very basic, could be made more homely”. The home needs to improve further its recruitment practices and ensure the home’s policies are followed and appropriate records are maintained at the home and made available for inspection at all times to protect and safeguard people who use the service. The internal environment needs attention to ensure that all rooms have all the essential equipment, items of furniture and fittings. Fire Safety and Health and Safety equipment and systems must be tested for safe working and maintained at all times in accordance with the relevant Health and Safety and Fire Safety legislation. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Bethrey House care home provides adequate information to prospective people who will be using the service and their families to enable them to make decisions about whether or not they wish to live at the care home. People who will be using the service receive a needs assessment prior to admission to ensure that their needs will be met. The current needs assessment format needs updating and amending to ensure that there is a full/comprehensive needs assessment available for all people with dementia who will be using the service. The home’s Statement of Purpose and Service Users’ Guide also needs updating to reflect the recent changes in its registration and Care Homes Regulations 2001 (as amended). Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 11 EVIDENCE: Admissions are not made to the home until an initial assessment has been undertaken. However, it was noted that a service user was admitted on 18th June 2008 without obtaining in advance a needs assessment from the local Social Services Department. The Care Manager stated that she is pursuing this matter with the relevant Social Worker and added that this will not happen again in the future. Another service user’s needs assessment was incomplete. At present the Care Manager visits and completes an initial assessment form for all people who use the service at their home or hospital prior to admission. There was evidence in the 4 files/care plans of people using the service that were seen which contained initial/brief pre-admission assessments carried out by the home, and the remaining three had needs assessments carried out by other relevant professionals. The Care Manager stated that she will be revising and updating the needs assessment information to ensure that the staff in the home have full/comprehensive information on the needs of people who use the service. She also stated that all the risk assessments will be updated by using the new revised format. The Care Manager also stated that she will revise and update the home’s Statement of Purpose and Service Users’ Guide to reflect the recent changes in its registration and also recent changes to the Care Homes Regulations 2001 (as amended). Observations and discussions with the people using the service, the Care Manager, and staff on duty indicated that despite the recent changes in staff, and staff vacancies, the home continues to meet the basic individual needs of all the older people with dementia accommodated at the home in a sensitive manner. It was noted from the staff training records that ten members of staff have received training in Dementia care and three carers are also currently undertaking their Positive Dementia training. The Care Manager stated that all members of staff who as yet have not received training in Dementia care will do so as a matter of priority in order to increase their awareness, knowledge and skills about the care needs of people using the service. The home does not provide a service for those assessed and referred solely for intermediate care, who require help to maximise their independence and return home. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Each service user has an individual plan of care but these do not detail how their needs will be met. Health care needs are addressed promptly. Medication is managed safely and people who use the service are protected by the home’s policy and procedures. People who use the service are treated with respect and dignity, and their rights to privacy are understood and upheld. EVIDENCE: All people who use the service undergo an assessment of their needs prior to admission to the care home, either by the care home and other relevant professionals i.e. Social Workers. As it was noted in the previous section that the current needs assessments does not contain full/comprehensive Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 13 information about people who use the service and thus it also reflected on the quality and details contained in the care plans. The Care Manager stated that currently the care plans are produced, which are based on the initial assessment of needs. It was noted that the home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Four care plans/files of people who use the service were examined in detail and it was noted that the short-term and long-term goals, aims and objectives were not clearly identified and appropriate interventions required to put them into action to meet the individual residents’ needs also were not identified. It was also noted that risk assessments in some aspects have not been carried out or not updated. For example, one new service user’s needs assessment was not fully completed and thus the care plan was also incomplete. The care plan review of this service user had not yet taken place. In addition, 3 other service users’ needs assessments were incomplete and were in need of updating. It was acknowledged by the Care Manager that the recent high turn over of care staff and inadequate staffing levels has contributed to this deficiency in some of the care plans that have not been reviewed and updated for the last few weeks, and stated that these care plans will be updated by the end of September 2008. It was also acknowledged by the Care Manager that insufficient number of staff on duty also could have adverse effect on the quality of person-centred care for individual service users with Dementia care needs. The Care Manager also must explore ways in which to involve the people using the service and their relatives in care plans reviewing processes. Where this is not possible due to the nature of the mental health problems/dementia needs experienced by some of the people who use the service this should be clearly documented in the care plans. Daily care records were also seen and entries made by care staff could not always be cross-referenced to the uncompleted care plans. The daily care (day and night) recording formats were also examined and it was noted that the quality and detail of care recording needs further improvement. The Care Manager stated that she will ensure the staff are aware of the importance of including all the information regarding people who use the service and their well - being, and all the entries made by the staff are always to be cross-referenced to their care plans. The Care Manager also stated that the revised and updated formats of care plans and daily care recordings will be implemented immediately; and the staff will be closely supervised and supported to make further improvements in daily care recordings as a matter of priority. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 14 The home maintains records of all health checks carried out by doctors, opticians, district nurses and chiropodists. People who use the service are assessed by the senior staff to determine whether or not they are at risk of developing any pressure sores. District Nurses visits the home regularly and support staff with the provision of pressure relieving equipment as necessary. The Care Manager confirmed that at present there is no service user in the home with pressure sores. The home also completes a dietary needs assessment that details each person’s abilities at meal times and lists their likes and dislikes and the type of help needed. All people using the service are weighed monthly, which helps staff to monitor their health well - being and physical conditions. People who have specific conditions such as diabetes, mental health needs and epilepsy generally had management plans in place to ensure that staff were aware of their individual needs. All of the people using the service have some form of dementia and occasionally they display some behaviour that challenges staff and/or other people who use the service. This means that staff may find these situations difficult to handle and meet the needs of people who use the service without specific guidance and training. This was discussed with the Care Manager during the inspection and she is to discuss this matter with the Registered Provider and then take appropriate action to provide staff with guidance on managing such likely behaviours and to organise appropriate training on these issues for staff. Medication Practices within the home have improved since the last inspection. The medication cupboard was found to be clean and tidy. Medicines were stored appropriately. Evidence gathered from staff records and from discussions with the Care Manager showed that several members of care staff have received training in safe handling of medication. Now this training will ensure that the staff are aware of the processes involved in administering medicines and enable them to do it safely. Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines have been given. The Care Manager stated that all senior carers, who are responsible for the handling and administration of medication have completed their training in safe handling of medication. Records seen included medication received, administered and leaving the care home. It was noted that the mobile medication trolley was securely stored after use in the dining room and medicines are kept under lock and key in a medication cupboard in the manager’s office. It was noted on the day of inspection that no personal interventions were undertaken in communal areas. In addition, consultations with health and social care professionals were carried out within the bedrooms of people using the service. Visitors were able to meet people using the service in their Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 15 bedrooms and the main lounge. It was also observed that the people using the service were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. Staff were working hard to try and maintain the dignity of people using the service, which can be difficult at times due to the type of illness and conditions they have. Relatives have commented that they are pleased with the care their relatives received, but sometimes there are difficult situations that the staff are having to deal with. Additional care staff could help the residents. The Care Manager stated that she will discuss the staffing situation with the Registered Provider and the particular needs of people using the service and the need to provide additional staff to provide care for people who use the service. We spoke at some length with several people using the service, who were able to have meaningful conversation; they stated they were happy with the care provided and staff were very helpful and caring. Three people using the service stated that “the carers are always there to help, and we are very pleased with them”. However, during the discussions with people using the service they also said that “on many occasions the carers are pushed for time when they have to cover sickness and other duties when there were fewer carers on duty, and this was true in the morning, afternoon and weekends”. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide a structured programme of social and leisure activities and outings, which are designed to meet the needs, preferences and capabilities of people using the service with dementia. People who use the service are helped to exercise control over their lives as far as it is practicable and safe to do so. The dietary needs of people who use the service are well catered for with a balanced and varied selection of foods, and ample quantities to meet the tastes and individual requirements of people using the service. EVIDENCE: It was noted that the home does not provide a structured programme of social and leisure activities inside and outside of the home in accordance with people who use the service with dementia care needs, their preferences and capabilities. There is inadequate system of maintaining records of activities in the home. The Care Manager said that at present there is no one clearly identified to lead on co-ordinating the activities programme, and there was no evidence of any co-ordination. The Care Manager needs to ensure that the Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 17 carers (key workers) should identify the interests that the people using the service wish to pursue and also always to be mindful of their capabilities and choice to participate in any proposed activity. At present the care plans do not clearly identify in detail the social and leisure needs of the people who use the service. It was also noted that there was very little in the way of entertainment and activities within the home and no outings and trips have been arranged during the recent months. The external entertainers are invited occasionally to deliver entertainment in the home for people who use the service. However, a singer provided musical entertainment in the afternoon on the day of inspection. But not specific activities for people with dementia care needs and their abilities. The Care Manager stated that she will ensure that the social and leisure activities needs are clearly identified in their care plans, and any activities enjoyed by the people using the service will be appropriately and consistently recorded, evaluated and incorporated into their individual care plans. Activities seen during the afternoon on the day of inspection included listening to music, and a couple of service users were doing some colouring/painting with a member of staff. Several people who use the service were engaged in conversation with each other whilst the others were watching television. Several people who use the service spoken to stated that they are in regular contact with their family members and friends, and spoke about their visitors’ interest and some involvement in their care matters. The visitors’ book kept in the home showed a considerable activity. Family and friends are encouraged to visit and the home has an open visiting policy. There was a steady flow of visitors during the day of inspection. Two visitors commented that “its good to see the residents taking part in doing some activities, and its good for them, but more staff would be helpful”. During our meeting with staff it was noted that the recent staffing shortages has impacted on the organisation and co-ordination of activities for people using the service. There is no spare staff capacity or time to provide any meaningful individual or small group based social and leisure activities. The outdoor activities – outings/trips has not happened due largely to the recent staff shortages. Relatives of two people who use the service stated that they visit the home at various times of the day as they wish. Two relatives who spoke to us said they are given warm and friendly welcome by the staff whenever they visit. Some people who use the service also keep some contacts with the local community – for example, local shops. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 18 The Care Manager stated that the people who use the service are assisted and helped to exercise choice and control over their lives as far as practicable and safe to do so, and subject to risk assessments. A close liaison is maintained with the relatives and representatives where the people who use the service are not able to make decisions. People who use the service and their relatives are informed about the availability of the local Advocacy Service based at the local Age Concern office. Several people who use the service told us “the food is very nice and tasty”. The consensus of people who use the service was the range, quality and choice of food provided was good and the home caters for those people who use the service who have individual preferences and medical needs. The Care Manager stated that the current four weekly menus has been changed recently in consultation with the people who use the service and also taking into account their health needs. The cook has completed her NVQ Level 1&2 in food hygiene and also infection control training. The Registered Provider needs to take appropriate action to address the issues noted below: The First-Aid box needs checking and to be stocked with the required items; and there were several weeks gaps in the records maintained of daily food eaten by people using the service and which needs to be kept up to date. The daily fridge and freezer temperature records were not consistently maintained. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and professionally. People who use the service are protected from abuse by the home’s policies and procedures. Formal training is required for all staff to ensure that people who use the service are protected from all forms of harm and abuse. EVIDENCE: The home has a good Complaints Procedure, which is referred to for information in the Service Users’ Guide and Statement of Purpose. There is a satisfactory system of recording concerns and complaints. Since the last inspection there has been no formal complaints received against the home nor any safeguarding referral made. Two relatives of people who use the service when asked were certain of how to formally make a complaint but said they would quite happily talk to one of the staff in charge or the manager. The home has policies and procedures in place regarding the prevention of abuse. The home also has a copy of Wolverhampton’s multi-agency vulnerable adults protection/safeguarding procedures. The home has a whistle – blowing policy in place. The Care Manager stated that adult protection issues are discussed during staff induction training and supervision meetings. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 20 However, formal training in adult protection issues has not been provided to all members of staff. The Care Manager stated that there are several members of staff who as yet have not received this mode of training but will do so as a matter of priority. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained but needs some improvements to furniture, fittings and safety matters. The home is clean and hygienic. EVIDENCE: A tour of the premises highlighted a number of issues that must be addressed to the internal environment. The Care Manager stated that there is a planned programme for maintenance with timescales for specific jobs, including redecoration of bedrooms and communal areas, and renewal of old furniture, fittings and floor covering. The two relatives commented about the décor within the home and stated that some areas would benefit from renewal. The hot water supply in majority of bedrooms was tested and the hot water was Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 22 found to be well above the recommended temperature level of close to 43 Degrees C. The hot water temperature varied from 32 Degrees C to 55 Degrees C in the bedrooms and 45 Degrees C to 47 Degrees C in the bathrooms. The above issue was discussed with the Care Manager and she called out a plumber in the afternoon on the day of inspection and appropriate action was taken to rectify the inconsistent hot water supply in the home and it was made safe for the use of people using the service. The Care Manager stated that she will ensure the people using the service enjoy a regular supply of hot water without the risk of scalding or not having the consistent supply of sufficiently hot water at all. The main lounge has been fitted with a new carpet. The Care Manager stated that the suitable floor covering is being provided in several bedrooms as part of the rolling programme of redecoration and refurbishment. The majority of bedrooms are in need of the provision of suitable lockable facility for safe keeping of money and/or valuables for the use of the people living at the home. A window restrictor is needed in bedroom 21 on the first floor in order to ensure the safety of the service user occupying this bedroom. The Care Manager stated that this window will be fitted with a suitable restrictor immediately and henceforth all window restrictors will be checked on a more regular basis for the risk and safety of people who use the service. The self-closure mechanisms fitted on several bedroom doors were in need of checking and adjusting to ensure that they close properly to their rebate in the event of fire to ensure safety of people using the service. The door to bedroom 6 on the first floor was not closing properly to its rebate and the smoke seal was coming off the door and thus posing a high risk in case of fire and in need of urgent repair/replacement. The staff are making use of a bathroom for changing and storing their personal items. A locker for staff use is also stored in this bathroom, but the individual locks does not work and there are no keys available. It was also noted that there is no suitable provision made for storage for the purposes of the care home. Unused items of furniture and wheelchairs etc. are stored in the service users’ bedrooms and bathrooms. Broken overhead lights in bedrooms 14 needs repairing/replacing appropriately. There is no bedside light available in bedroom 17. There were several bedrooms where fused light bulbs in the overhead lights needs replacing in order to ensure safety for people who use the service. The extractor fans in the WCs and bedroom en-suite facilities on both floors were not in working order and need repairing appropriately. There are a number of bedrooms without suitable tables to sit at for people using the service. The home has two bathrooms in use for 19 service users. The Care Manager and the Deputy Manager stated that the shower on the ground floor is not suitable and it is unsafe to use and inaccessible for the current service users. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 23 The Registered Provider need to take appropriate action to address the above issues to ensure comfortable and safe environment at all times for the people who use the service. The AQAA received from the care home states that “We have improved in the last 12 months – new carpet in the communal lounge, new flooring in some rooms and outstanding requirements have been met”. The AQAA also states that “ Our plans for improvement in the next 12 months are – to update some furniture in bedrooms and redecorate where needed”. The home was found to be clean, tidy and free from any unpleasant odour. The Care Manager stated that the floor covering in the bedrooms are being replaced as rolling programme. The home has good policies and procedures regarding infection control. It was also noted from the staff training records that a majority of staff have received training in infection control. The Care Manager stated that those members of staff who as yet have not received this mode of training will do so as a matter of priority. The Care Manager stated that the home has had an Infection Prevention and Control Audit on 1st July 2008 carried out by Wolverhampton City PCT – Infection Prevention and Control Team. The overall result of the Audit was 97 , which is an excellent score. We saw a copy of the Audit Report. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty on day shifts needs to be revised and improved sufficiently to meet the needs of 19 people with dementia. The recruitment procedures have not improved and do not protect people using the service. The home continues to support staff to complete training, but not all staff are yet adequately trained to do their jobs. EVIDENCE: Staff rotas are maintained to show which staff are on duty at any given time of day and night. The Care Manager hours are not included on the rota. She told us that she only works Monday to Friday between 8.00 am to 4.30 pm. The deputy manager or the senior carers always cover at the weekends. There is a minimum of one senior carer and two carers on duty in the morning shift and a senior carer and a carer in the afternoon shift and in some evenings a carer works between 6.30 pm to 8.30 pm and two carers on wakeful duty at night. However, information provided by the home and the available staff rotas on the day of inspection indicated that this level of staffing is not always adequate to meet the needs of 19 people with dementia using the service. The home employs a cook to cover 6 days a week and a domestic assistant for 5 days a Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 25 week; there is no cook cover for the evening teatimes throughout the week. Therefore, one of the two staff on duty in the afternoon is expected to provide a meal at teatime throughout the week with additional cooking and cleaning duties at the weekends. The home also does not employ a laundry assistant and the care staff are also expected to provide cover for the laundry duties throughout the week. In addition, the carers on duty during the day are expected to undertake social and leisure activities for the 19 people who use the service. These additional duties mean that there are effectively only two staff available on the floor to provide care and supervision to 19 people with dementia care needs, located in the lounge and conservatory areas, with some service users who may wish to stay in their bedrooms on two different floors. During our meetings with the staff, they stated that they feel under pressure and “pushed” for time in the mornings and afternoons and more particularly during the weekends. It was noted that as the numbers of people who use the service have now increased and their dependency levels have risen the staff were struggling to provide quality time and a good person-centred care. In such circumstances the staff have very little time to provide or to organise structured daily social and leisure activities including outdoor outings/trips. Staff were spoken to and all stated that despite the changes in staff recently, they felt they were for the better and they were beginning to work as a team. There is good balance within the staff team, which includes experienced, mature and younger staff, who are embarking on a new career. The staff team also have a good ethnic and gender mix. The relatives spoken with also made observations about the staff team “they all are working hard in the present circumstances to provide good care and attention to our relatives here”. People who use the service were full of praise for care staff stating “they are caring and kind and do anything for us”. It was also noted that the home is now registered for 19 people who use the service with dementia care needs. The references to staff deficiencies also have been highlighted in earlier sections of this report i.e. - Health and Personal Care, and Daily Life and Social Activities. The Care Manager’s hours are in addition to the staffing hours referred to above to allow her time to manage the care home. In order to provide a good standard of care and up keep of the home, the Registered Provider need to review the staffing levels and then need to take appropriate action to provide adequate numbers of care and ancillary staff on duty at all times. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 26 It was noted from the staff training records and discussions with staff and Care Manager that there are over 50 members of staff, who have completed their NVQ Level 2 training and four carers are currently undertaking their NVQ Level 2 training. The Care Manager stated that the remaining staff will undergo this mode of training shortly. It was also noted that a number of staff have undertaken their mandatory training in safe working practice topics. It was noted also that not all members of staff have received training in safe working practice topics and some members of staff need to update their training in this area. The Care Manager stated that they will be put forward to undertake this mode of training shortly. Staff will also be nominated to receive training in adult protection and safeguarding issues, equality and diversity, Mental Capacity Act 2005, challenging behaviours and Dementia care. The staff records showed that new staff only received the basic in-house induction training. The Care Manager stated that all new members of staff will receive their induction training in accordance with the Skills for Care standards/requirements. We held meetings with staff on duty and they confirmed that they are being supported by the home for any training needs that they have. However, the Care Manager stated that she will compile a staff training list/matrix which will provide detailed information on staff training programme. Since the last key inspection, the home has not operated an acceptable recruitment procedure. On inspecting 5 staff files, it was noted that not all staff recruited recently have their POVA and CRB Disclosures available in the home. Two written references were also not have been obtained in two cases. The staff records seen showed that two carers recruited recently have been employed without CRB and POVA checks. There was no evidence available in the home to show that the CRBs for new members of staff have been applied for. However, the Care Manager acknowledged that there were some gaps in the above areas, which will be rectified immediately. The job application forms were fully completed and contain full employment history. The Care Manager stated that any gaps in employment are also explored/discussed with the job applicants during the interviews. There was evidence on files that staff receive statements of the terms and conditions of employment. There is now a staff training and development programme in place, which is being implemented. The Care Manager stated that she will ensure that the home continues to refine and follow the staff recruitment processes/procedures in order to ensure that the people who use the service are safe and protected from any harm and abuse. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 27 Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Care Manager is developing systems that monitor practice and compliance with plans, policies and procedures of the home and is aware of the need to keep up to date with practice and continuously develop management skills. Financial interests of people who use the service are safeguarded. The home promotes the health, safety and welfare of people using the service, but needs some further improvements. EVIDENCE: The AQAA received in July 2008 from Bethrey House showed that some improvements have been made in the environment of the home, care practices and staff training opportunities. The home has also improved interaction with Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 29 service users and involving them in their care plans and listening to what they want and listening to comments and suggestions made to the home. The Care Manager has completed her NVQ Level 4 qualification in November 2007 and now she is undertaking her RMA qualification, which she hopes to complete in October 2008. There are clear lines of responsibility and accountability within the home and the Care Manager is well supported by the Area Manager and the Registered Provider. The home has a formal staff supervision system in place and now this is being implemented. It was seen from the staff supervision records that some members of staff have not received their regular supervision from the Care Manager and there were some gaps in this area. However, the Care Manager stated that she will be organising supervision dates with those members of staff who as yet have not received their formal supervision. Observations made and discussions with people who use the service and their relatives and staff have indicated that the Care Manager is very approachable and she operates an “open” door policy. People who use the service, who could express themselves stated that they are happy to approach the Manager and staff with any problems they might have and were confident that they would respond to them appropriately. Equality and diversity for service users were seen to be promoted throughout the home within the assessments, care plans, menus, and activities. Equality for staff is promoted through the opportunities for training at all levels. It was noted that the home has a Quality Assurance monitoring system in place. However, the questionnaires and analysis report on the feedback on the quality of services provided by the home were not available for inspection at the home for the year 2007. The Care Manager confirmed that she has distributed recently the questionnaires to people using the service, and their relatives. Ms Sims stated that she will complete the report on the outcome of the feedback by the end of September 2008 and the report will be made available in the home and a copy to the CSCI. However, the home also needs to obtain feedback from other stakeholders and visitors to the home and analyse their responses as well. In addition, the Care Manager should consider developing systems for determining the views of people using the service with Dementia/mental health needs, who are unable to verbalise their needs. The Registered Provider also need to undertake his formal monthly visits to Bethrey House care home under Regulation 26 of the Care Homes Regulations 2001 (as amended), and ensure the reports of these visits are made available in the home and also for CSCI inspections. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 30 Financial records and administrative procedures relating to the handling of monies of four people who use the service were inspected and were found to be well ordered and maintained. However, the Care Manager stated that she will ensure that all the receipts of incoming and outgoing expenditure will be kept together and appropriately numbered. All the money belonging to people who use the service is kept in a safe and under lock and key. Only the Care Manager and her Deputy Manager have access to the safe in the home. The home has good health and safety policy and procedures, and staff are aware of their responsibilities regarding these issues and a number of staff have received training in these issues. All safety systems and equipment are regularly checked and well maintained and records of all tests/checks are kept up to date. The tests on hoists in the bathrooms, and mobile hoists in the home, passenger lift and wheelchairs are undertaken on a regular basis to ensure the safety of people using the services in the home. However, fire alarm system, emergency lighting system and staff call system were serviced in August 2007 and were due to be undertaken again later this month. Water for Legionnaires was tested on 14th April 2007 and due for tests again shortly. The records showed that the gas boiler was checked/serviced by a CORGI qualified engineer on 6th December 2007. The PAT testing had been not carried out, which was due to be undertaken on 7th July 2008. The temperature of hot water supply in home is tested regularly and last test record showed between 41 Degrees C to 43 Degrees C. However, our tests on the afternoon of the day of inspection showed inconsistent supply of hot water in the home. In order to ensure safety of people who use the service this deficiency was addressed promptly on the day of our inspection by the home. The Care Manager stated that she will follow up the other above issues immediately and make contact with the relevant contractors to undertake these works urgently. The staff training records indicated that there were some gaps in mandatory training for staff that includes fire safety, moving and handling, first-aid, health and safety, a fully qualified first– aider to be on duty to cover all shifts, infection control, COSHH and food hygiene. The Care Manager stated that the Registered Provider is aware of this deficiency and they are taking appropriate steps to rectify this unsatisfactory situation shortly. Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 2 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation Requirement Timescale for action 30/09/08 2. OP27 13(4(b)(c) The home must ensure that 13(5) unnecessary risks are identified and minimized through use of risk assessments. This is to ensure that as far as possible people remain safe. 18 The Registered Provider must 30/09/08 ensure that care and ancillary staff must be provided in sufficient numbers to ensure that the care needs of people who use the service, particularly those with dementia, can be met. 19 The home must ensure that two 15/09/08 written references and one of these from the last employer, CRB and POVA checks must be obtained on all new staff prior to their commencement of employment in order to ensure safety and protection of people who use the service. New staff must receive their 15/09/08 induction training in accordance with the Skills for Care standards and requirements to ensure the safety and protection of people DS0000020882.V368773.R01.S.doc Version 5.2 3. OP29 4. OP30 18 Bethrey House Page 33 who use the service. 5. OP38 23 (2) (j) The home must take appropriate action to ensure a consistent supply of hot water at a safe temperature at all times. This is to ensure that people using the service enjoy a regular supply of hot water without the risk of scalding. The Registered Provider must ensure that staff who as yet have not received mandatory training in respect of: • Fire Safety • Health and Safety • First Aid • Moving and handling • Food Hygiene • Infection Control do so in order to ensure the safety and protection of people using the service. 15/09/08 6. OP38 18 30/09/08 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 OP1 Good Practice Recommendations The Care Manager takes appropriate action to revise and update the home’s Statement of Purpose and Service Users’ Guide to reflect the home’s current registration and also in line with the recent changes to the Care Homes Regulations 2001 (as amended). The Care Manager takes appropriate action to revise and update the home’s current needs assessment format in DS0000020882.V368773.R01.S.doc Version 5.2 Page 34 2. OP3 Bethrey House order to ensure that detailed and comprehensive information is obtained at the point of initial needs assessment process. 3. OP7 The Care Manger takes appropriate action ensure that all the care plans of people using the service contain clear and detailed goals, aims and objectives recorded, and detail and quality of daily care recording should be further improved in order to ensure that staff are aware of the importance of recording all information regarding the wellbeing of people using the service, and all the entries made by staff are always cross-referenced to care plans. The Care Manager also should develop guidelines for staff to follow when service users display aggressive/challenging behaviours in order to safeguard and protect both staff and people who use the service. The Care Manager should ensure that age appropriate activities are arranged at time suitable for the individual. A suitable member of staff should be nominated to act as an activities co-ordinator in the home. The activities should be varied in range and appropriate, and in accordance with the service users’ choice, preference and capabilities. Records of all activities enjoyed by the people who use the service should be incorporated into the individual service user plans. The Home should take appropriate action to ensure that all staff receive training in adult protection and safeguarding issues, Dementia care, equality and diversity, Mental Capacity Act 2005, aggressive/challenging behaviours and mental health needs, in order to fully meet the needs of, people who use the service. It is strongly recommended that the Registered Provider should give serious considerations to the complete refurbishment of the shower room and to make it usable by the current service users. The Home should take appropriate action to obtain feedback from stakeholders and visitors to the home on the quality of services and facilities provided to people using the service, as part of the home’s Quality Assurance monitoring systems. The Registered Provider should undertake his formal monthly visits to the care home and make available copies of these monthly visits at the care home and must be available for inspection by the Commission for Social Care DS0000020882.V368773.R01.S.doc Version 5.2 Page 35 4. OP12 5. OP30 6. OP21 7. OP33 Bethrey House 8. 9. OP33 OP24 Inspection (CSCI). The Care Manager should develop systems for determining the views of people using the service who are unable to verbalise their needs. It is recommended that all bedrooms be provided with a suitable locking facility and suitable tables to sit at for the use of people who are living at the home. It is strongly recommended that a sluice disinfector be purchased to reduce the risk of cross - infection and to reduce the risk to staff of splash back accidents. The Care Manager should take appropriate action to ensure that all the Fire Safety and Health and Safety equipment, systems and mechanisms are regularly tested and serviced and maintained in working order at all times in accordance with the relevant Health and Safety and Fire Safety legislation. 10. OP26 11. OP38 Bethrey House DS0000020882.V368773.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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