Inspection on 26/09/06 for Harpenden Bethesda Home

This inspection was carried out on 26th September 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Harpenden Bethesda Home 14/02/06

Harpenden Bethesda Home 07/06/05

Harpenden Bethesda Home 15/02/05

Harpenden Bethesda Home 14/07/04

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

CARE HOMES FOR OLDER PEOPLE Harpenden Bethesda Home 201 Luton Road Harpenden Hertfordshire AL5 3DD Lead Inspector Alison Jessop Key Unannounced Inspection 26th September 2006 10:00 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 Harpenden Bethesda Home DS0000019406.V313679.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. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harpenden Bethesda Home Address 201 Luton Road Harpenden Hertfordshire AL5 3DD 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) 01582 761 359 01582 460 790 Gospel Standard Bethesda Fund Rachel Susan Verweij Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: Harpenden Bethesda Home, provided by the Gospel Standard Bethesda Fund, is a purposed built residential home accommodating up to twenty-three service users in the old age category. The organisations head office is on the same site but in a separate building. There are ample parking spaces within the grounds. The home is situated in the town of Harpenden and within easy reach of public transport and the local shops. The building is well maintained both externally and internally. The interior is appropriately decorated to give a homely appearance. The entrance hall leads to a large and spacious lounge. The administrative office is opposite the lounge. The kitchen has a serving hatch that leads to a spacious dining room, which is neatly and attractively arranged. At the end of the dining room is a storage room for medication and clinical supply. There is a small self-serve area in the hallway that sells items such as confectionary, cards and wrapping paper. There are nineteen single bedrooms and two shared double bedrooms. All the bedrooms have en-suite washbasin and toilet facilities. The number of assisted bathrooms are adequate for the registered number of service users. The home has a large and attractive garden that faces the front entrance to the building. It is bordered by mature trees and provides comfortable seats for the service users and visitors. All the rooms and the garden are accessible to wheelchair users. A copy of the most recent CSCI inspection report can be located near the visitors signing in book in the reception area. The current accommodation charges range from £383.95 to £442.40 per week. Service users pay for other services such as hairdressing or chiropody privately. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over half a day by one regulatory inspector. Feedback was gained from most of the service users, staff and visitors. Although the registered manager was unavailable, the responsible individual and deputy manager were available to answer any questions. Feedback was also gained from a chaplain who is a regular visitor to the home. Records maintained in the home were also inspected. What the service does well: What has improved since the last inspection? What they could do better: Medication procedures are generally satisfactory although care must be taken to ensure medication is stored in accordance with the manufacturers instructions to ensure its effectiveness. The carpets in the communal hallways looked stained in areas and thorough cleaning is recommended. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 6 Procedures relating to recruitment are generally satisfactory, however one criminal record disclosure had been transferred from a previous employer. A more appropriate location must be used to store confidential and sensitive information. 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. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 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 the following standard(s): 3&6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service considers carefully the needs assessment for each prospective resident before agreeing admission to the home. Prospective residents and their family, always have the opportunity to visit and spend time in the home prior to admission. EVIDENCE: A comprehensive needs assessment is carried out by a person trained to do so and consideration is given prior to agreeing admission. One service user said ‘I came to visit several times before I moved in, I was made to feel very welcome.’ The home does not provide intermediate care. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have individual health care plans that give a comprehensive overview of their general health and acts as an indicator to changing health needs. The home works to an efficient medication policy supported by procedures and practice guidance. EVIDENCE: Each service users care plan is updated on a monthly basis or more frequently if required. Care practice observed was sensitive and attention is given to ensuring privacy and dignity when delivering personal care. One service user said ‘the carers are very kind and helpful.’ Medication procedures are generally satisfactory although care must be taken to ensure medication is stored in accordance with the manufacturers instructions to ensure its effectiveness. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 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 the following standard(s): 12,13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff team give service users the opportunity and support to remain independent. Residents are able to enjoy a full and stimulating life style with a variety of activities to choose from. Mealtimes are relaxed, and food is wholesome, nutritious and is served to meet the needs of all service users. EVIDENCE: Each day a volunteer from the Baptist Church visits the home to offer a bible reading. Although this is carried out in the lounge, service users can hear the reading in their bedrooms as there is a speaker placed in each room. Service users can also be taken to a local Baptist Church to attend a service. The visiting chaplain was extremely complimentary about the home and staff. The home has a mini bus and regular outings are arranged. Service users had enjoyed a trip to a safari park and for those that were unable to go, an indoor picnic was arranged. Other trips include a trip to St Albans Park and museum and lunch at a local garden centre. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 11 A range of activities are organised in the home such as crafts, knitting blankets and making food packages for third world charities. Several service users were observed doing tasks such as handing out bibles, collecting teacups and other chores to keep them busy and promote independence. The menu offers wholesome, nutritious and freshly cooked alternatives. The cook said that she gains suggestions from service users who all said that the food is excellent. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 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 the following standard(s): 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and others associated with the home state that they are extremely satisfied with the service provision, feel very safe and well supported. The home ensures through training, supervision, review and quality monitoring that care staff fully complies with the policies and procedures provided in relation to protecting and safeguarding the rights of the residents. EVIDENCE: No complaints have been received by the home since the previous inspection. Several compliments had been received. Staff confirmed that they receive training on Adult Abuse and were aware of the Protection of Vulnerable Adults procedure. Staff are supervised on a monthly basis. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 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 the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well-maintained environment, which provides a very pleasant, homely safe place to live. EVIDENCE: The home is very well maintained and offers a homely, relaxed atmosphere to service users. The gardens are attractive and tidily maintained and offer a pleasant, accessible outdoor area to relax. The home is very clean and procedures relating to infection control are followed. The carpets in the communal hallways looked stained in some areas and thorough cleaning is recommended. No malodours were detected. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. EVIDENCE: On the day of the inspection the home was adequately staffed. Staff demonstrated their skills and knowledge in caring for service users. There is a rolling training programme and a number of staff have completed or are currently completing an NVQ qualification. Procedures relating to recruitment are generally satisfactory, however one criminal record disclosure had been transferred from a previous employer. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager ensures that the policies and procedures are followed by staff. Staff have access to practice handbooks and all documents. The registered persons are very committed to ensuring the health, welfare and safety of residents and staff. Records are clearly written and up dated. There is strong evidence that the ethos of the home is open and transparent with the views of both staff and residents listened to, and valued. EVIDENCE: Staff spoken to were aware of the policies and procedures within the home and receive regular supervision where policies can be discussed. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 16 A quality assurance audit is carried out annually where the views of service users, relatives and stakeholders are sought. The most recent audit was carried out in March 2006 and the results were very positive. Service user care plans were stored on a shelf in the manager’s office; a more appropriate location must be used to store confidential and sensitive information. Records relating to health and safety were satisfactorily maintained and staff are aware of risk assessments. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 17 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 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 18 Are there any outstanding requirements from the last inspection? NO 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 OP29 Regulation 19 Schedule 2 (7) 17(1)(b) Requirement The registered person must not employ a person to work in the home unless he/she has been subject to satisfactory criminal reference disclosure. All records relating to service users care must be stored confidentially. Timescale for action 26/10/06 2. OP37 26/10/06 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 OP9 OP26 Good Practice Recommendations It is recommended that medicines such as Lactulose should be stored below 20°C in accordance with manufacturers instructions. It is recommended that the carpets in communal hallways be thoroughly cleaned to remove heavy stains. Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Harpenden Bethesda Home DS0000019406.V313679.R01.S.doc Version 5.2 Page 20 - 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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