CQC report explained · a nursing home
What the CQC found at Bethany House Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2020
Rated Good; inspectors found safe, kind and personalised care, with minor medicines records and staff checks needing improvement.
This was an unannounced inspection on 21 January 2020. The inspectors spoke with people, relatives and staff, and checked care records, medicines records, staff files and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were happy with the care. Inspectors found detailed care plans, enough staff, safe risk management and kind, respectful support.
There were some minor shortfalls. These included records for controlled drugs and food supplements, renewing some long-serving staff DBS checks, and staff dress code. The manager acted on these issues during or immediately after the inspection.
Managing risk
Inspectors found a proactive approach to assessing and managing risks. This helped people remain as independent as possible.
“There was a proactive approach to assessing and managing risk which allowed people to remain as independent as possible.” from the report
Kind and respectful care
People were treated with kindness, dignity and respect. Staff also supported people's independence and involvement in decisions.
“People were treated with kindness and their dignity and their independence was promoted.” from the report
Activities and relationships
The home offered a varied programme of activities and helped people maintain friendships and links with the local community.
“The service employed a team of activities coordinators who planned a variety of activities each day.” from the report
Improved leadership
Quality checks had improved since the previous inspection. Managers involved people, relatives and staff and worked with outside professionals.
“Quality monitoring systems were in place and used to monitor the service.” from the report
Medicines records
needs fixingThere were minor gaps in recording controlled drugs and food supplements added to drinks. The manager acted on these immediately.
“Some minor shortfalls were found with the recording of controlled drugs records and supplements added to people's drinks.” from the report
Renewing staff DBS checks
needs fixingSome long-serving staff needed their DBS checks renewing. The manager acted on this immediately.
“Appropriate recruitment checks had been made. However, some long-serving staff DBS' required renewing.” from the report
Staff dress code
minorMinor changes to staff dress code were needed to meet good practice guidance.
“However, minor improvements to staff dress code were required to comply with good practice guidance.” from the report
- 01Have all controlled drug and food supplement recording issues been corrected, and how are these records checked now?
- 02Have the DBS renewals for all long-serving staff been completed?
- 03What changes were made to the staff dress code after the inspection?
- 04What refurbishment work remains, and how will it affect people living in the home?
- 05How are people, relatives and staff currently involved in quality checks and decisions about the home?
This was a planned, unannounced inspection covering all five CQC questions; inspectors reviewed the premises, care, records and the views of people, relatives and staff. This explanation was written from the published report of 8 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2019
Bethany House Care Home rated Requires Improvement; inspectors found kind and responsive care, but ongoing safety and management failures.
This was an unannounced comprehensive inspection on 16 January 2019. Inspectors spoke with people using the service, relatives, staff and outside professionals. They reviewed care records, recruitment files, medicines records and other documents.
The home was rated Good for Effective, Caring and Responsive. People were treated kindly, had care plans that reflected their needs, received support with health and nutrition, and had activities and opportunities to stay in contact with family and the community.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found people could enter or leave through unlocked doors without staff noticing. Some hazardous rooms were left open, bed rail safety was not always followed, and infection control practices were not always used.
The home continued to breach the rules on safe care and treatment and good governance. Some improvements had been made since March 2018, including medicines management and staffing, but the inspection found that quality checks still failed to identify important risks.
Kind and respectful care
People and relatives consistently described the care positively. Inspectors observed staff supporting people patiently and respectfully.
“The service treated people with compassion, kindness, dignity and respect.” from the report
Reliable staffing
Staffing levels had increased since the previous inspection and were sufficient for people's needs. Recruitment checks helped ensure staff were suitable.
“People received support from a reliable and consistent staff team.” from the report
Improved medicines management
Medicines systems had improved since the previous inspection. Staff received training and competency checks, and controlled medicines were stored securely.
“The provider had made improvements to their systems for the safe management of medicines.” from the report
Activities and personal care planning
People had a range of activities and care plans reflected their needs, preferences and changing risks.
“The provider made opportunities available for people to participate in a wide range of activities to help alleviate social isolation.” from the report
People could leave unnoticed
seriousInspectors found that people, including those living with dementia, could leave through unlocked doors without staff awareness. This created a risk of harm.
“We saw it was possible for either people who may be living with dementia to leave the service or for members of the public to enter the building without being noticed by staff.” from the report
Safety and infection control checks
seriousBed rail protective covers were missing in some cases. Inspectors also found infection control practices that could increase the spread of infection.
“We saw some people were being nursed in bed using bed rails without the required protective covers (bumpers) to prevent entrapment.” from the report
Quality checks missed risks
seriousThe home's monitoring systems had not identified the safety problems found by inspectors. This was a continued management concern.
“Quality monitoring systems failed to mitigate risks relating to the health, safety and welfare of people living at the service.” from the report
Mealtimes were not always timely
needs fixingSome people waited for help with meals, so food was not always served hot and on time. The manager said mealtime monitoring would be undertaken.
“At times we observed people were waiting for support with their meals which meant that they were not always having their food hot and on time.” from the report
- 01How have you secured the entrances so that people cannot leave unnoticed and unauthorised visitors cannot enter?
- 02Are the sluice, laundry and cleaner's cupboard now locked whenever staff are not using them?
- 03How do you check that bed rails have the correct protective covers and are being used safely?
- 04What changes have been made to infection control procedures, including the storage and movement of linen and lifting equipment?
- 05How do your current quality checks identify and act on safety concerns before they affect people?
This was an unannounced comprehensive inspection covering all five key questions and both the premises and care provided; the previous inspection was in March 2018. This explanation was written from the published report of 28 February 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bethany House Care Home
4 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
47 live-in carers within about an hour of County Durham
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £960 to £1,210 a week. 42 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.