Care Home: Bethrey House

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What the care home does well The home provides a relaxed, comfortable and friendly atmosphere where people are treated with respect and in a dignified way. The home makes every effort to provide people with good care to meet their assessed needs following a care plan. The home has a good key worker system and staff supervision system in place. The home communicates well with the families, friends and representatives of people who use the service and welcomes visitors. People who use the service say they are happy and content with living in a homely and caring place. The comments we received via returned Surveys included: • “The home make my mom and us feel like a family to them and always very welcome”. (a relative on behalf of a resident) “Bethrey House provides a very high level of care to its residents, with the staff knowing the residents well and providing a caring environment for them to live”. (a health care professional) “Staff are always very welcoming. They are exceptionally caring and appear to go that ‘extra mile’ to ensure their residents are happy and very well cared for”. (a social care professional)••People who use the service are often vulnerable both physically and emotionally and the Registered Provider and the Registered Manager ensure that staff recruited have the ability to carry out personal care services for people sensitively and tactfully. The recruitment of good caring staff is critical to the running of care homes and the Registered Provider and the Registered Manager at Bethrey House undertake this carefully. The home has a good staff training and development programme in place. A majority of staff have received mandatory training in safe working practice topics including : safe handling of medication, adult protection and safeguarding issues and National Vocational Qualification (NVQ) Level 2. Thus this training will ensure that the staff have improved their knowledge and skills to meet the changing needs of people who use the service. The home provides good standard of accommodation and facilities for people using the service.Bethrey HouseDS0000020882.V376791.R01.S.docVersion 5.2 What has improved since the last inspection? People commented that: • “Lots of recent improvements to décor and fittings etc. I am pleased that it looks much better now”. “The facilities and the care provided by management and staff is far better than previous years”. “Everything that I have witnessed up to date is carried out with care and regard to the residents’ well being”.••The home has an experienced Registered Manager in post and she has developed good skills in managing the care home well. Conversations with staff, people using the service and their visiting relatives, indicated that the Registered Manager is service user focused, leads and supports an enhanced staff team providing them with improved training and supervision. This style and approach to management aims to pursue future improvements in all aspects of service. One person who lives at the home stated that “This place is a lot more peaceful and better organised now”. The home has made some good improvements in their record keeping and care planning. Care Plans seen for people who use the service were informative and gave good indication of how care is to be delivered for each of them. Medication practices have improved and more senior staff have received training in safe handling of medication. The home has organised staff training on Dementia care and challenging behaviours. A majority of staff have received training in safe working practice topics, adult protection/safeguarding and National Vocational Qualification (NVQ) Level 2 and that will enable them to expand their knowledge and skills and enhance the care they give to people using the service. What the care home could do better: The home should continue to improve further the detail and quality of daily care recordings. Activities enjoyed by the people who use the service shouldBethrey HouseDS0000020882.V376791.R01.S.doc Version 5.2 be consistently recorded, evaluated and incorporated into their individual care plans. Those members of staff who as yet have not received training in safe working practice topics, including safe handling of medication, Dementia care, NVQ Level 2, adult protection and safeguarding issues must do so as a matter of priority. This training would enable staff to improve further their care practices, knowledge and skills. The AQAA submitted prior to this visit by the Registered Manager stated that “We will continue monitoring of our services, improve care plans with changing needs. Offer more days out and shopping trips. Continue with training of staff and ensure staff supervision is maintained”. Key inspection report CARE HOMES FOR OLDER PEOPLE Bethrey House Bethrey House 43 Goldthorn Hill Penn Wolverhampton West Midlands WV2 3HR Lead Inspector Bhag Jassal Key Unannounced Inspection 30th July 2009 08:50 DS0000020882.V376791.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Bethrey House DS0000020882.V376791.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.V376791.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 5th August 2008 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 care home. Weekly fees range from £361.00 - £ 412.00. Information of the home and the provision of the service are available in the Statement of Purpose and Service Users’ Guide. Care Quality Commission’s inspection reports for this service are available from the Registered Manager or can be obtained from www.cqc.org.uk. Bethrey House DS0000020882.V376791.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 2 Star. This means the people who use the service experience Good quality outcomes. This report is on a Key Inspection, part of which includes an unannounced visit undertaken on 30th July 2009. The unannounced visit started at 08:50 and lasted 8 hours and 20 minutes. The home had 16 people in residence and three vacancies. The judgements made within the report are based upon information supplied by the home, from interviews with the Registered Manager, the staff and people who use the service and their relatives. During the course of inspection the assessment information and care plans were examined. 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. We looked at areas of the home used by people living there and observed care practices and interaction between staff and people using the service. 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. Registered 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 assessed – that is those areas of service delivery that are considered essential to the running of a care home that ensure the best outcomes for people living at Bethrey House. Regulation 37 Notifications, concerns and complaints against the home and Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager and submitted to the Care Quality Commission (CQC) prior to this inspection were considered. The AQAA is a self - assessment and a dataset that is filled in once a year by all Registered Providers. It informs us about how Registered Providers are meeting outcomes for people using their service and is an opportunity for Registered Providers to share with us areas that they believe they are doing well. Information within this document demonstrates that the Registered Manager recognises the strengths and weaknesses within the service and is able to plan for improvement. We wish to thank the Registered 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.V376791.R01.S.doc Version 5.2 Page 6 What the service does well: The home provides a relaxed, comfortable and friendly atmosphere where people are treated with respect and in a dignified way. The home makes every effort to provide people with good care to meet their assessed needs following a care plan. The home has a good key worker system and staff supervision system in place. The home communicates well with the families, friends and representatives of people who use the service and welcomes visitors. People who use the service say they are happy and content with living in a homely and caring place. The comments we received via returned Surveys included: • “The home make my mom and us feel like a family to them and always very welcome”. (a relative on behalf of a resident) “Bethrey House provides a very high level of care to its residents, with the staff knowing the residents well and providing a caring environment for them to live”. (a health care professional) “Staff are always very welcoming. They are exceptionally caring and appear to go that ‘extra mile’ to ensure their residents are happy and very well cared for”. (a social care professional) • • People who use the service are often vulnerable both physically and emotionally and the Registered Provider and the Registered Manager ensure that staff recruited have the ability to carry out personal care services for people sensitively and tactfully. The recruitment of good caring staff is critical to the running of care homes and the Registered Provider and the Registered Manager at Bethrey House undertake this carefully. The home has a good staff training and development programme in place. A majority of staff have received mandatory training in safe working practice topics including : safe handling of medication, adult protection and safeguarding issues and National Vocational Qualification (NVQ) Level 2. Thus this training will ensure that the staff have improved their knowledge and skills to meet the changing needs of people who use the service. The home provides good standard of accommodation and facilities for people using the service. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? People commented that: • “Lots of recent improvements to décor and fittings etc. I am pleased that it looks much better now”. “The facilities and the care provided by management and staff is far better than previous years”. “Everything that I have witnessed up to date is carried out with care and regard to the residents’ well being”. • • The home has an experienced Registered Manager in post and she has developed good skills in managing the care home well. Conversations with staff, people using the service and their visiting relatives, indicated that the Registered Manager is service user focused, leads and supports an enhanced staff team providing them with improved training and supervision. This style and approach to management aims to pursue future improvements in all aspects of service. One person who lives at the home stated that “This place is a lot more peaceful and better organised now”. The home has made some good improvements in their record keeping and care planning. Care Plans seen for people who use the service were informative and gave good indication of how care is to be delivered for each of them. Medication practices have improved and more senior staff have received training in safe handling of medication. The home has organised staff training on Dementia care and challenging behaviours. A majority of staff have received training in safe working practice topics, adult protection/safeguarding and National Vocational Qualification (NVQ) Level 2 and that will enable them to expand their knowledge and skills and enhance the care they give to people using the service. What they could do better: The home should continue to improve further the detail and quality of daily care recordings. Activities enjoyed by the people who use the service should Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 8 be consistently recorded, evaluated and incorporated into their individual care plans. Those members of staff who as yet have not received training in safe working practice topics, including safe handling of medication, Dementia care, NVQ Level 2, adult protection and safeguarding issues must do so as a matter of priority. This training would enable staff to improve further their care practices, knowledge and skills. The AQAA submitted prior to this visit by the Registered Manager stated that “We will continue monitoring of our services, improve care plans with changing needs. Offer more days out and shopping trips. Continue with training of staff and ensure staff supervision is maintained”. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Bethrey House DS0000020882.V376791.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.V376791.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that the care home supports them as people have all the information they need before they move into the Home. EVIDENCE: Bethrey House care home provides detailed and clear information, in the form of a Service Users’ Guide, to people who will be using the service and their families to enable them to make decisions about whether or not to live at the home. Admissions are not made to the care home until a full assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. For people who are self - funding and without a care Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 11 management assessment, they always receive assessment by the Registered Manager. Four files/care plans of people who use the service were inspected, which contained pre - admission assessments of their needs, both from assessments by the home’s senior staff and other relevant professionals. Observations and discussions with people using the service, their visiting relatives, the Registered Manager, and staff on duty indicated that the home continues to meet the needs of older people in a satisfactory and sensitive manner. It was noted from the staff training records that a majority of staff have undertaken their training in Dementia care, Mental Capacity Act 2005, including Deprivation of Liberty Safeguards (DoLS) and adult protection and safeguarding issues. 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.V376791.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have individual plans of care, which ensures that their personal, healthcare and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People who use the service are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: People who use the service undergo an assessment of their needs prior to admission to the care home. A Care Plan is produced, which is based on the assessment of needs. The home operates a good key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Four Care Plans of people using the service were inspected Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 13 and examined in detail. There was evidence to show that the short - term goals and long - term goals, aims and objectives were clearly identified and appropriate interventions required to meet the individual needs of people who use the service were also identified. However, the home needs to improve further the detail and quality of daily care recording. The Registered Manager stated that care staff will be closely supervised and supported to achieve this. Discussion with people who use the service showed that the home has a good ethos of involving them in all aspects of their life. The care plans that were read were clearly written and included an element of risk assessment. Information from the initial assessments had been written into plans of care. The care plans are reviewed on a monthly basis by senior staff. Care Plans demonstrated that the staff actively promoted the rights of people who use the service of access to the health services both within the home and the community. Appointments are planned or arrangements are made for professionals to visit frail people using the service. Whenever possible continuity of care for the declining state of health of people who use the service is assured. District Nurses are called upon to assist with clinical help, equipment and advice where necessary. The Registered Manager promotes the key worker system so that relationships between staff and individuals are enhanced. Visitors are able to meet people using the service in their bedrooms, in the lounge or conservatory on the ground floor. It was observed that people who use the service were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. We spoke at length with several people using the service and all of them commented positively about their care and felt they have everything that they need. Four people who use the service stated that “The carers are very good and kind and they look after us very well”. Two other people who use the service said “The carers are always there to help us”. Generally people who use the service appeared to be content and comfortable. They were complimentary regarding the quality of their lives and care they were receiving at Bethrey House care home. A completed Survey received states “Bethrey House provides good quality of care for all service users. We have very good, friendly staff who are always available to deal with anything and who put all service users and their needs first”. Another visiting person stated “Bethrey House is a very welcoming home. All the residents are very happy. The staff are very professional and very approachable and extremely helpful”. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 14 There are appropriate policies and procedures in place for the administration of medication. It was noted that the care plans contained a list of current medication. The Registered Manager stated that reviews are carried out on a regular basis of all the care plans to ensure that medication details are up to date. Appropriate records are kept of all medicines received, administered and leaving the home. Random sample of medication and administration sheets were seen at the inspection and there were no discrepancies. All the medicines are stored in the Manager’s office kept under lock and key. Daily checks are taken of the temperature of the medicines in the refrigerator and the Manager’s office. There are no controlled drugs used at present by any service user at the care home. However, if there is a need to store such drugs securely and safely in a lockable metal cupboard, which is available in the Registered Managers office. Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines had been given. The Registered Manager stated that all senior staff responsible for administering medication were appropriately trained in safe handling of medication. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to exercise choice with regard to social and leisure activities at the home. Activities provided meet the needs of the people using the service. Relatives and friends are encouraged and assisted to maintain contact with the people using the service. The food at the home is of good quality and choices are always available. EVIDENCE: The home provides an activities programme in accordance with everyone using the service, their choices, preferences and capacities in relation to social, leisure and cultural interests. People using the service, who were able to give opinion, were very complimentary about the activities provided, and particularly the external entertainers. People who use the service are enabled to enjoy a full and stimulating life style with a variety of options to choose from. A record of activities participated in is kept and photographs of major Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 16 events displayed in the home. However, the activities enjoyed by the people who use the service needs to be evaluated, consistently recorded and incorporated into their individual care plans. This will ensure quality outcomes for people who use the service and enable the service to improve further its activities programme for the benefits of people living at Bethrey House. People using the service were seen sitting in the lounges chatting to staff and visiting relatives and in other communal areas within the home. Two people who use the service stated that they preferred to sometimes sit quietly in their bedrooms and the staff respected this. After lunch time a number of people who use the service were engaged in playing different games or watching television. The Registered Manager stated that the home organises entertainment delivered by external entertainers, for example, craftwork, music and exercise. There have been outings to Oaks Court, Church Service in Willenhall, theatre, Black Country Museum and RAF Cosford Park. There is a weekly activities programme which include board games, relaxation therapy, bingo, painting and colouring, skittles, chair aerobics and use of a light therapy room for people who wish to have quite time or people with Dementia or stress to take time out and relax. On the day inspection there was a clothing party whereby the service users, relatives and staff could purchase new clothes. Several people using the service spoken to stated that they were in regular contact with their family members and friends, and spoke about their visitors’ involvement and interest in their care matters. The visitors’ book kept in the home showed a considerable activity. People who use the service also keep contacts with the local community, for example, church services, pubs, shops and park. Five people told us that they are happy with the care and social activities offered by the care home. They further added “the home provides a good service and the staff are very caring and they are pleasant”. The home also provides a variety of indoor activities, including festive and birthday parties. The Registered Manager stated that the people who use the service were positively encouraged and helped to exercise their choices, and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. The Registered Manager also stated that a close liaison is maintained with the relatives and representatives, where the people are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the home’s Statement of Purpose and Service Users’ Guide. Several people who use the service told us “The home is very good and its peace and quiet here”. “The food was very nice well cooked and tasty”. The Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 17 consensus of people using the service was the range, quality and choice of food provided was very good and the home catered for those people using the service, who have individual preferences and medical needs. The Registered Manager stated that the menu is changed regularly in consultation with the people who use the service. This is usually done in accordance with seasonal changes as well. The kitchen is well equipped and kept clean and tidy. However, at present, the home does not have a provision of a dishwasher. The Registered Manager stated that this issue will be addressed shortly. The catering staff are trained in food safety and hygiene matters. As a result of recent improvements made by the home, the Environmental Health Officer’s report dated 15th June 2009 has upgraded it from 1 Star to 3 Star premises. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Home safeguards people from abuse and takes appropriate action to follow up allegations. This ensures that any complaints made are listened to and acted upon. The home has an Adult Protection and safeguarding policy and procedure in place to protect people who use the service from all forms of abuse. EVIDENCE: The home has a good Complaints Procedure in place, which is referred to in the home’s Service Users’ Guide and in the Statement of Purpose. There is a system of recording concerns and complaints. The AQAA completed by the Registered Manager states “We have a comprehensive complaints procedure and ensure that all service users and their families are aware of how to make a complaint. Our complaints procedure and procedures for dealing with abuse are highlighted in the Service Users Guide, which is issued on admission. The Care Quality Commission (CQC) has not received any complaint about the care home, or any adult protection and safeguarding referral. However, the Registered Manager stated that the home has received five informal Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 19 concerns/issues raised by people who use the service and their relatives, which were fully investigated and resolved to their satisfaction. People, who use the service, when asked, were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff or the Manager. The home has good policies and procedures in place regarding restraint, dealing with aggressive behaviour and prevention of abuse, which includes whistle - blowing policy. The Registered Manager stated that adult protection and safeguarding issues are discussed during induction training and supervision meetings. The Registered Manager stated that a majority of staff have received formal training in protection of vulnerable adults and safeguarding and those who as yet have not received this training or updates will do so shortly. She also stated that trainers have been approached to set up this training. Training in Mental Capacity Act 2005, including Deprivation of Liberty Safeguards (DoLS) is being held in September 2009. Several people who use the service stated they are satisfied with the service provision, feel safe and well supported by staff that have their protection and safety as a priority. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment provides a homely, clean and secure place to live. EVIDENCE: The home offers a comfortable and well - maintained environment to all people who use the service. The home has ample communal space – a lounge/dining room and a conservatory. The home has a rolling programme of redecoration to maintain good standards. The large garden and patio areas at the rear are well - maintained. The home has provided suitable aids and adaptations in the home to meet the general and specific needs of all the people using the Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 21 service. There are adequate numbers of bathrooms and WCs in the home. It was noted that the bedrooms are “personalised” by most of the people using the service. The Registered Provider should give serious considerations to refurbish the shower located on the ground floor, which is not accessible and usable by the present people who use the service. During the day of inspection, the home was found to be clean, tidy and free from any unpleasant odour. The AQAA completed by the Registered Manager states that, new carpets in the lounge/dining room have been provided. A number of bedrooms have been redecorated and provided new flooring. However, looking around the premises we noted the following issues:• That a suitable lockable facility to be provided in bedroom 9, and also a suitable table to sit at to be provided in bedroom 14 for the appropriate use. • That the restrictors fitted to the window in bedroom 21 on the first floor is not safe for person living in this room; and also the restrictors fitted to a numbers of other bedrooms also need refitting to ensure the safety of people using these bedrooms. • That the self - closure mechanism fitted on several bedroom doors in need of adjusting to ensure that the doors fully close to their rebate. This is to ensure the safety of all people using the service. • The locks fitted to both bathroom doors do not have the ability to open them from outside in case of emergency and could place people using the service at safety risk. The Registered Manager stated the above issues will be addressed immediately. The home has good policies and procedures in place regarding infection control. The Wolverhampton Primary Care Trust’s Infection Prevention and Control Team conducted an infection prevention and control audit on 1st July 2008 and the overall result of the audit was 97 , which is an excellent score or gold award for the home. It was also noted from the staff training records that almost all members of staff have undertaken training in infection control. It was noted that all new members of staff received induction training and they are made aware of the dangers of cross – infection. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is staffed by well - trained and experienced staff to meet the needs of people who use the service. There are robust recruitment procedures in place to protect people who use the service. There is a good training programme in place that ensures staff are competent to do their jobs. New members of receive structured induction training. EVIDENCE: Information provided by the home and available staff rotas for the months of June and July 2009 indicated that the home has sufficient care staff to meet the needs of the 16 people using the service at present. There is one senior carer and two carers on duty in the morning and one senior carer and two carers in the afternoon shift. Two carers are on wakeful night duty and a senior member of staff on - call. The Registered Manager’s hours are supernumerary. There are adequate numbers of ancillary staff employed in the home to cover catering and cleaning duties throughout the week. However, it was noted that Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 23 the carers are expected to undertake laundry duties in addition to their caring duties, and also one of the carers on the afternoon shift have to go into the kitchen and prepare and distribute the evening tea. The Registered Manager stated that she will discuss this kitchen and laundry staff matters with the Registered Provider with the view to getting dedicated members of staff to undertake the catering duties at the evening teatimes and also laundry duties. By doing so, this will enable allocated care staff to remain with, provide care and supervise the people to ensure their welfare and safety is maintained at all times. The staff training records showed that a majority of staff have completed their NVQ Level 2 qualification and several members of staff have also completed their NVQ Level 3 training. The remaining members of staff who as yet have not received this training will also be nominated to undertake this training shortly. The home does not employ Agency staff. The staff team is a well balanced group in terms of age, experience, gender and ethnicity. Four staff files were examined in detail in order to check compliance with the recruitment requirements. All four files contained copies of two written references, and a full employment history. There was evidence on staff files that all four had been subject to satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks prior to being appointed. There was evidence on files that staff have received the statements of their terms and conditions of employment. There is a staff training and development programme in place. In addition to the mandatory training (see NMS OP38) staff also have benefited from training in adult protection and safeguarding issues, Mental Capacity Act 2005, equality and diversity, and physical aggression/challenging behaviours. Staff confirmed that training is provided and there are many opportunities to improve themselves for the benefit of the care of people using the service. All new staff received their induction training in accordance with the Skills for Care standards and specifications. People who use the service commented that they feel safe with staff caring for them and they felt that the home employs people that are capable of carrying out their care duties. Surveys completed and returned by staff states “I enjoy working at Bethrey House and have no concerns at this time”. “Due to last inspection, I have found the home improved. We have improved in the home in all areas – care work, laundry and cooking. Bethrey House has been a lot better to work over the last 12 months”. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be assured that overall the home is run for their interests. Financial interests of people using the service are safeguarded. The home promotes the health, safety and welfare of people who use the service. EVIDENCE: The Registered Manager – Ms Helen Sims has completed her NVQ Level 4 qualification and now she is undertaking her Registered Managers’ Award (RMA) qualification, which she hopes to complete by the end of 2009. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 25 There are clear lines of responsibility and accountability within the home and the Registered Manager is well supported by the Area Manager and the Registered Provider. The home has a formal staff supervision system in place and Ms Sims is implementing the system of supervision of staff and meetings both with staff and people who use the service. Observations made and discussions with people who use the service and their relatives and staff have indicated that the Registered 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. The Registered Manager confirmed that she has distributed 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 2009 and the report will be made available in the home and a copy to the CQC. 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 Registered Manager should consider developing systems for determining the views of people using the service with Dementia care and mental health needs, who are unable to verbalise their needs. 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. All the money belonging to people who use the service is kept in a safe and under lock and key. Only the Registered Manager and a senior carer have access to the safe in the home. The home has good health and safety policy and procedures in place, 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 and passenger lift are undertaken on a regular basis to ensure the safety of people using the services in the home. Fire alarm system, emergency lighting system and staff call system were serviced in May 2009. Water for Legionnaires was tested on 14th April 2007 Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 26 and due for tests again shortly. The records showed that all the required servicing and safety checks have been completed as required. However, it was noted that several self - closure devices fitted on the bedroom doors were in need of checking and appropriately adjusting to ensure they close properly to their rebate in order to protect people using the service from the risks of fire. The restrictors fitted to couple of windows on the first floor and on the ground floor to be repaired or replaced appropriately to ensure safety of people using the service. The Registered Manager stated that these issues will be addressed immediately. The Registered Manager also stated that the issues identified in the Environmental Health Officers inspection report dated 15th June 2009 have been addressed. The home has now improved from 1 Star to 3 Star premises. The staff training records indicated that there were very few 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 Registered Manager stated that the Registered Provider is aware of this small short fall and they are taking appropriate steps to rectify this shortly. She also stated that those members of staff who as yet not received training in adult protection/safeguarding issues, safe handling of medication, NVQ Level 2, Mental Capacity Act 2005 and Dementia care will do so shortly. The AQAA received in July 2009 from Bethrey House showed that many improvements have been made to the environment of the home, care practices and staff training opportunities. The home has also improved interaction with people who use the service and involving them in their care plans and listening to what they want and listening to comments and suggestions made to the home. People who use the service spoken with were also very complimentary about the Registered Manager and staff in the home. Many of them knew who they were by name and looked at ease in their presence. Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 27 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 ENVIRONMENT CHOICE OF HOME Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 X 3 X X N/A 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 Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 28 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. Standard Regulation 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 OP12 Good Practice Recommendations Records of all activities enjoyed by the people who use the service should be incorporated into the individual service user plans. 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 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 DS0000020882.V376791.R01.S.doc Version 5.2 Page 29 2. OP21 3. OP38 Bethrey House Infection Control do so in order to ensure the safety and protection of people using the service. 4 OP19 The home should take appropriate action to ensure that essential maintenance and repairs, such as those identified in this report are dealt with promptly. This is to ensure that people live in a comfortable, secure and safe home. 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 Manger takes appropriate action to ensure that 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 and challenging behaviours in order to safeguard and protect both staff and people who use the service. 7. OP30 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 including Deprivation of Liberty Safeguards, aggressive and challenging behaviours and mental health needs, in order to fully meet the needs of, people who use the service. 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 Care Manager should develop systems for determining the views of people using the service who are unable to verbalise their needs. 5. OP1 6. OP7 8. OP33 9. OP33 Bethrey House DS0000020882.V376791.R01.S.doc Version 5.2 Page 30 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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