Inspection on 07/06/05 for Harpenden Bethesda Home

This inspection was carried out on 7th June 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 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 26/09/06

Harpenden Bethesda Home 14/02/06

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 Yoke-Lan Jackson Unannounced 7 June 2005 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. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Harpenden Bethesda Home Address 201 Luton Road, Harpenden, Hertfordshire, AL5 3DD 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) 01582 761 359 01582 460 790 Gospel Standard Bethesda Fund CRH Care Home 23 Category(ies) of OP-23 registration, with number of places Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Older People (23) Date of last inspection 15 February 2005 Brief Description of the Service: Harpenden Bethesda Home is a purposed built residential home accommodating up to twenty-three service users in the old age category. It is provided by the charitable organisation, Gospel Standard Bethesda Fund. The organisation’s head office is on the same site but in a separate building. There are ample parking spaces within the ground. The home is situated in the town of Harpenden. It is suitably located and is 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 dinning room, which is neatly and attractively arranged with dinning furniture and ornaments. At the end of the dinning room is a storage room for medication and clinical supply. All the bedrooms have en-suite washbasin and toilet facilities. There are nineteen single bedrooms and two shared double bedrooms. The assisted bathrooms and toilet facilities are adequate for the service users and staff.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 garden are accessible to wheelchairs. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection (Unannounced) for the year 2005. The inspection took six hours. The home manager was present. The inspection centred on general observation, including staff performance and staff interaction with the service users, conversation with the service users and with the visitor and discussions with the staff and the home manager. The standard of care and services provided continue to be maintained to a high standard. The service users, relatives and visitors only have compliments for the staff. To date the home has not received a written complaint, only complimentary letters. (Please see below for details of the inspection findings). What the service does well: What has improved since the last inspection? All the floor tiles in the building were replaced with non-slip tiles to ensure a safe environment for all the service users and staff. The staffing level for permanent staff has improved since the last inspection. The vacancy for a permanent night care worker has been filled. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 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 Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 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) 1, 2, 3, 4. The manager will conduct a full assessment to ensure that the home is able to meet the needs and aspirations of the prospective service users. EVIDENCE: The Statement of Purpose and the Service User Guide have been revised. A copy of these has been forwarded to the Commission for Social Care Inspection (CSCI). The manager may have to turn down a prospective service user following a recent assessment as the home may not meet all his needs. Each service user is given a copy of the signed written contract and the Service User Guide on admission to the home. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 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, 9, 10. The care planning system ensures that all the needs and aspirations of the individual service user are met in an appropriate way. The assessed and changing needs were reflected in the individual care plan. Service users are treated with respect and dignity at all times. Their right to privacy is respected. The home manager ensures that the administration of medication is in accordance with legislation. EVIDENCE: The service users spoken with during this unannounced inspection expressed their gratitude and said that they are very pleased to be cared for in the home. There were no negative remarks expressed. A recent letter addressed to the Commission from the relatives of one service user expressed their gratitude to the staff with these words: “The staff showed great love and respect at all times making sure that her comfort and wellbeing were their foremost concerns. Each task, even if very unpleasant, was accepted as an opportunity to express their love for her.“ Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 10 The care plans examined gave details of the healthcare needs and the personal, social and spiritual needs of the respective service users. The home has the support of the local General Practitioner, the District Nurse and other healthcare workers who attend regularly and when requested by the home. The members of staff interact well with each other and with the service users. Good team working is prevalent in the home. The home manager ensures that the administration of medication is in accordance with legislation and the guidelines from the Royal Pharmaceutical Society. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 The service users are given the opportunity to participate in all aspects of routine living, including recreational interests and religious needs. They are given choices and their preferences are respected. The service users enjoy time spent together at Bible Study and at mealtimes. The meals presented are appealing and nutritious. Relatives and friends are encouraged to visit at any reasonable time. EVIDENCE: The service users spoken with in the lounge confirmed that choices are given with regard to their activities and menu. A Bible Reading Service is held daily as part of the services offered in the home. Practically all the service users attend the daily service, which is held in the spacious lounge. A volunteer from the Strict Baptist Church conducts the service. The weekly activity programmes include outings and church attendance in midweek. Transportation is provided. Mealtime is unhurried and it is held in a relaxed, homely atmosphere in the dining room. The staff give assistance when needed. The individual service users may have meals in their own room but the majority preferred to use the dining room. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18. The service users and the relatives are aware of the complaints procedure. The home manager ensures that the service users are protected from abuse and that their legal rights are protected. EVIDENCE: The home’s Complaints Policy and Procedure are available to all service users and their relatives. A copy of the Hertfordshire Vulnerable Adult Procedure is kept in the office. The home is not involved in the financial affairs of the service users. The service users make their own arrangements, usually with relatives’ involvement. All staff are cognisant of the Whistle-Blowing process. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 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, 20, 21, 23, 24, 25, 26 The service users live in an environment that is homely, safe, and clean. The en-suite facilities in the bedrooms are adequate for the respective service users. The bedrooms are clean and comfortable. EVIDENCE: The premises are clean and tidy and well-maintained. The surrounding grounds provide a pleasant and relaxed garden for the service users to take their daily walking exercise. Since the last inspection, all the floor tiles within the building have been replaced with non-slip materials. The bedrooms examined have personal items on display that reflect the individual lifestyle of the service user. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 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 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, 28, 29, 30 The home has an effective and dedicated team of workers. The skill mix of the staff benefits the service users. The recruitment and selection process meet the requirements of the legislation. The home has a dedicated group of staff. Their on-going training meets the needs of the service users. EVIDENCE: The members of staff have demonstrated their dedication and commitment to caring for the service users. Feedback from the service users confirmed that they are very well looked after. One service user commented: “I am very happy in the home. I have no complaints.” Another said: “The carers are all wonderful.” The manager ensures that new staff commence employment after passing the police checks as well as the Protection of Vulnerable Adult checks. The home has recently recruited a permanent night care worker who is shadowing senior staff in the administration of medication. Further training will be provided for her. Some members of staff are currently undergoing training to attain the BTEC Award in the Principles of Administration and Control of Medication. All staff had training organised by the District Nursing Service (Harpenden) in relevant topics such as The Recognition and Prevention of Pressure Ulcers on 28th April 2005. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 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 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) 31, 32, 33, 37, 38 The home is well administered and well-managed. It is run in the best interests of the service users. The health, safety and welfare of the service users are promoted and maintained. The manager has taken steps to ensure that the standard of care and services continue to be maintained to a high standard. EVIDENCE: The home has not received any complaint and it continues to receive compliments from service users and their relatives, visitors and professionals. A couple of professionals have remarked to staff that Harpenden Bethesda is the type of home where they would like to be cared for. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 16 The manager ensures that all statutory records and associate records are up to date. All personal service user files and employee files are kept locked in the office. Service users have access to their personal records on request. The manager ensures that the health and safety checks are maintained with risk assessment in place when necessary. Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 4 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 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 3 3 3 3 3 x x x 3 3 3 Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 18 No 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 Regulation None Requirement Timescale for action 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 None Good Practice Recommendations Harpenden Bethesda Home I52 s19406 Harpenden Bethesda Home v231979 070605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts 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. 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