CQC report explained · a nursing home
What the CQC found at Bethany House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2021
Bethany House Care Home was rated Requires Improvement; inspectors found medicine, staffing and care-record problems, although recent improvements were being made.
This was an unannounced focused inspection on 23 February 2021. Inspectors looked at Safe and Well-led because of concerns about staffing, medicines and nursing care. They spoke with people, relatives and staff, observed care, and checked care plans, medicine records, staff files and management records.
The home was not always safe. Some medicines had not been given as prescribed and records were inconsistent. Care plans did not always give enough detail about risks, and daily records did not consistently show that people had received the care they needed. Staffing levels had recently increased, but there were still concerns about staff experience and knowledge.
The home was not always well-led. There was no registered manager, and oversight of some clinical risks and records was not effective. The provider had improvement plans and had made some recent changes, but not all planned actions were complete. The overall rating fell from Good at the previous inspection to Requires Improvement.
Safe recruitment
The home checked staff qualifications, character, skills and values. Nurses' registration was also checked.
“Staff were recruited safely. Checks of staff qualifications and character had been carried out and their skills and values had been assessed at interview.” from the report
Infection control
Inspectors were assured about testing, visitors, shielding, social distancing, protective equipment, hygiene and outbreak arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Learning from incidents
The home investigated incidents, updated care plans and risk assessments, and shared learning with staff.
“Learning outcomes were recorded after incident investigations; these were shared with staff.” from the report
Open culture
Staff described teamwork and an open, honest and person-centred culture. People and relatives found the manager approachable.
“Staff described the culture as open, honest and person-centred.” from the report
Medicine errors
seriousSome people did not always receive medicines as prescribed. Inconsistent records had contributed to medication errors, including one person receiving incorrect medicines.
“People had not always received their medicines as prescribed and inconsistent documentation had led to medication errors.” from the report
Incomplete care records
needs fixingSome care plans did not give enough detail about medical warning signs. Daily records did not consistently show that repositioning, food and fluid support had been provided.
“Not all care plans contained enough detailed information about peoples' needs.” from the report
Staffing experience
needs fixingThere were concerns that staff did not always have the right experience, skills and knowledge. Agency, temporary and newer staff might not know people well enough.
“There was not always enough staff with the right experience, skills and knowledge to meet peoples' needs in the right way.” from the report
Weak oversight
needs fixingManagers had not identified gaps in some risk records and the improvement plan was still incomplete. The home also did not have a registered manager.
“There was no effective oversight of risk management tools such as repositioning charts or food and fluid intake.” from the report
- 01What has changed since the inspection to prevent medicines being missed, given incorrectly or recorded wrongly?
- 02How do you check each person's repositioning, food and fluid support is completed and recorded?
- 03Who is currently managing the home, and has a registered manager now been appointed?
- 04How do you ensure agency, temporary and newly appointed staff understand each person's medical risks, including diabetes or epilepsy?
- 05Which actions from the quality improvement plan are still outstanding, and when will they be completed?
This was a focused inspection of Safe and Well-led only; the other key-question ratings came from the previous comprehensive inspection. This explanation was written from the published report of 27 April 2021 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, January 2020
Rated Good; inspectors found safe, kind and personalised care, with some staff supervision and medicines guidance improvements still needed.
This was an unannounced planned inspection on 10 December 2019. One inspector spoke with people, relatives, staff and health professionals. They also observed care and checked care plans, medicines, staff files, accidents, complaints and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, safe medicines systems and good support for people's complex health needs.
People were treated with kindness and respect. Their care plans reflected their needs and preferences. Staff supported communication, activities, healthcare appointments and people's choices about daily life.
There were two areas to improve. Some guidance for medicines given when needed could be more personal. The manager also wanted to improve how often staff supervision took place and how work observations were recorded.
Kind and respectful care
Staff knew people well and treated them with warmth, dignity and respect. People appeared relaxed and comfortable with staff.
“Staff showed people kindness, compassion, respect and upheld people's rights to privacy and dignified care.” from the report
Personalised support
Care plans reflected people's specific needs and preferences. People and relatives were involved in reviewing care.
“Peoples care plans were personalised to reflect their specific support needs and individual preferences, and they and relatives were consulted and involved in reviewing these.” from the report
Safe staffing and recruitment
People, relatives and staff said there were enough staff. Recruitment checks were in place to assess whether new staff were suitable.
“People were protected by a safe system of staff recruitment that checked the suitability of new staff and conformed to regulations.” from the report
Medicines guidance could be more personal
needs fixingGuidance was in place for medicines given when needed, but inspectors discussed making some of it more personalised. The manager agreed to take this forward.
“Some additional personalisation of this information was discussed with the registered manager who agreed to take this forward.” from the report
Staff supervision records
needs fixingThe manager identified that the frequency of staff supervision and recording observations of staff practice should improve.
“Staff received supervision and appraisal but frequencies of supervision was an area the registered manager was looking to improve, along with recording the observations made of staff work practice.” from the report
- 01How often does each staff member now receive supervision and appraisal?
- 02How do you record observations of staff practice and follow up any issues?
- 03How is guidance for medicines given when needed personalised for each resident?
- 04How do you make sure staff understand each person's communication methods and preferences?
- 05What changes were made after the recent safeguarding alert?
This was an unannounced planned inspection covering all five CQC questions, with checks of care, medicines, staffing, the premises and quality systems. This explanation was written from the published report of 31 January 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.
Every inspection of Bethany House Care Home
2 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- April 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2020GoodSafe: GoodWell-led: Good
- June 2019
Registered with the Care Quality Commission on 13 June 2019.
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.
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