CQC report explained · a residential care home
What the CQC found at Bethany House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Bethany House was rated Requires Improvement; inspectors found kind care and safer medicines, but ongoing risks with the building, infection control and management.
This was an unannounced focused inspection on 11 and 19 November 2022. Inspectors spoke with people living at the home, relatives and staff. They reviewed care records, medicines records, policies, checks and meeting notes.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also rated Requires Improvement. Caring and Responsive were not inspected during this visit, so their previous ratings were carried forward.
Inspectors found people were treated kindly and staff generally knew them well. Medicines were managed more safely than at the previous inspection. However, the building needed substantial repair after a fire, infection control was not always effective, and the home did not have a registered manager in post.
The home remained in breach of regulations about safe care and treatment, premises and equipment, and good governance. The provider must send CQC an action report, and CQC said it would work with the local authority to monitor progress.
Kind and respectful care
Inspectors found that people received compassionate care and that staff understood their individual needs.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Improved medicines management
Medicines were administered, recorded and stored safely. People were supported to make their own decisions about medicines where possible.
“People were supported by staff who followed systems and processes to administer, record and store medicines safely.” from the report
Health support
People had access to health professionals and support to maintain their health and independence.
“People had health passports in place which were used by health and social care professionals to support them in the way they needed.” from the report
Staff knew people well
Staff understood people's needs and helped protect them from abuse. Longer-serving contract staff provided some consistency.
“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report
Unsafe and poorly maintained environment
seriousThe building and equipment were not always clean or properly maintained. Renovation and repair work after a fire was disruptive and had not been planned around people's needs.
“The environment had not been well maintained. Renovation and repair works had started at the time of the inspection following a recent fire in the service.” from the report
Risk and fire safety gaps
seriousSome safety equipment and risk records were not in place or were incomplete. Fire risk actions had not been completed promptly, and one bedroom door did not meet fire safety standards.
“Actions identified in a fire risk assessment carried out in April 2022 had not been actioned in a timely manner.” from the report
Infection control
seriousStaff did not always follow mask guidance, bedrooms were not always kept clean and tidy, and food was not always stored safely.
“Staff were not wearing face masks on the second day of inspection, in line with current government guidance and the providers own policy and procedures.” from the report
Weak management checks
seriousAudits had not identified or resolved important problems. Incidents were not consistently reviewed so that lessons could be learned, and there was no registered manager in post.
“The provider failed to ensure systems and processes were in place to assess, monitor and improve the service.” from the report
Limited activities and goal support
needs fixingPeople were not always supported to set and achieve their goals. Inspectors found limited social stimulation and no clear plans for some people's wish for more social interaction.
“There was a lack of social stimulation and activities within the service to help people achieve their personal goals.” from the report
Poor communication about building work
needs fixingPeople, relatives and staff had not been properly consulted or updated about the renovation work. Staff also said some concerns were not acted on.
“People and staff told us they had not been updated or consulted about the renovation work.” from the report
- 01What work has now been completed to make the building, bedrooms, equipment and fire arrangements safe?
- 02How are you protecting residents from disruption and sensory distress during the renovation work?
- 03When will the registered manager be in post, and who is responsible for the home until then?
- 04How are you checking that infection control, food storage, cleaning and safety equipment requirements are being followed every day?
- 05What individual activities and goals are now planned for my relative, and how will you review their progress?
This was a focused inspection of Safe, Effective and Well-led only; the Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 12 January 2023 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, August 2021
Bethany House rated Requires Improvement; inspectors found risks with infection control, the building, medicines records and management checks.
This was a focused inspection on 28 June and 6 July 2021. The inspector looked only at Safe and Well-led, after concerns about the condition of the building. Five people, two relatives and eight staff were spoken with, and care, medicines, maintenance and management records were checked.
Some parts of the service were not safe. Staff did not always use PPE correctly. Areas of the building were dirty or needed repair. Some risk assessments, medicines information and incident records were incomplete or out of date. Staffing levels were considered safe, but the tool used to assess staffing needs had not been updated.
The home had a consistent staff team who knew people well and supported people respectfully. Managers started taking action between the two inspection days. However, the overall rating fell from Good in 2017 to Requires Improvement because improvements had not been identified or completed quickly enough.
Consistent staff team
There was a stable team who knew people's needs, preferences and histories.
“There was a consistent team of staff supporting people.” from the report
Respectful support
Staff supported people in a person-centred way and promoted dignity and independence.
“People were supported to have maximum choice and control of their lives” from the report
Partnership working
The service made referrals when people needed more support and worked with health and social care professionals.
“Referrals were made to health and social care agencies when it was felt a person required further treatment or support.” from the report
Building condition and cleanliness
seriousSome areas were dirty and parts of the building and equipment needed repair. Inspectors found several examples that could compromise safety.
“Parts of the service were unclean. For example, we found a room which smelt of urine, and mould and dirt in several of the bathrooms.” from the report
Infection control
seriousStaff did not always wear the correct PPE, and there were limited places to put it on and remove it. COVID-19 risk assessments were not in place for everyone.
“Staff did not always wear PPE in line with government guidance.” from the report
Safety equipment and risk records
seriousEquipment used to alert staff when someone needed support had been broken for several months. Risk assessments were not always complete or up to date.
“Equipment used to monitor and alert staff if a person required support had not been working since April 2021 and remained broken at the time of our inspection.” from the report
Medicines information
seriousInstructions for medicines given only when needed were not always available or detailed enough. Risks linked to paraffin-based creams had not been assessed.
“Protocols for 'as and when required' medication were not always in place.” from the report
Management checks
seriousThe provider's audits had not found or dealt with problems quickly enough. The service also lacked a proper analysis of accidents and incidents.
“The audits and checks completed had not been effective in driving improvement and ensuring the quality of the service” from the report
Staffing review
needs fixingStaffing levels were considered safe, but the tool used to decide staffing needs had not been reviewed since November 2020 despite changes in the service.
“The dependency tool had not been updated since November 2020, despite there been changes within the service.” from the report
- 01Have all the cleaning, repair and security problems found during the inspection now been fixed?
- 02How do you make sure staff wear the correct PPE and complete all infection-control risk assessments?
- 03Are risk assessments, medicines instructions and incident records now complete and up to date?
- 04How do you check that the broken monitoring equipment and other safety equipment remain in working order?
- 05When was the staffing dependency assessment last reviewed, and how does it reflect current people's needs?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 25 August 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.
Every inspection of Bethany House
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- October 2017Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- August 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 2010.
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
28 live-in carers within about an hour of North Yorkshire
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 £1,010 to £1,290 a week. 27 can care for a couple. 12 years' experience on average.
“Carla has been a god send with the implementation of bringing mum back home from respite care.”
“She was always 'just present enough': attentive, available, kind and engaging, but without ever over-stepping any boundary”
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.