CQC report explained · a residential care home
What the CQC found at Bethany House Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks, falls, infection control, staffing and safeguarding were well managed. They also found some medicines stock and storage problems, which were raised with the manager and addressed during the inspection.
- Effective?
- Good
- People's needs were assessed and reviewed, staff were trained and health professionals worked well with the home. One person did not receive the support or equipment needed to make eating easier, and the manager said this would be put right.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people's likes and dislikes and supported choice, independence, communication, cultural needs and relationships.
- Responsive?
- Good
- Care plans were up to date and reflected people's changing needs, preferences and interests. People had flexible routines, activities and support to continue hobbies, and complaints were recorded and dealt with appropriately.
- Well-led?
- Good
- A new manager and operations manager had introduced clearer leadership, audits and action plans. People, relatives and staff felt able to share concerns, and feedback was used to improve the home.
What inspectors found, March 2019
Bethany House Limited was rated Good; inspectors found kind, person-centred care and major improvements since the previous inspection, with some medicines and mealtime issues addressed during the visit.
This was an unannounced inspection on 22 February 2019. Inspectors spoke with people living in the home, relatives, staff and a visiting health professional. They observed care, checked the building and reviewed care plans, medicines records, staff files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, up-to-date care plans, kind care, good links with health professionals and better systems for checking quality.
The previous inspection had rated the home Requires improvement because care plans were not always up to date and quality checks did not identify shortfalls. Inspectors found these problems had been put right. They also found some medicines recording and storage issues and one person did not receive the support they needed at mealtime. The manager dealt with these issues during the inspection.
Improved care planning
Care plans had improved significantly and accurately described people's needs, preferences, abilities and health advice.
“Care planning had improved significantly and had become more detailed. Plans were up-to-date and focused on the person's whole life” from the report
Kind and respectful care
People said staff knew them well, were patient and kind, and gave them choice and time.
“People were treated with dignity and compassion. They told us the staff team knew them well, took a genuine interest and were kind and caring.” from the report
Enough trained staff
Inspectors found sufficient staff on duty and a stable team with the skills to meet people's needs.
“Staffing levels were sufficient to provide safe and individual care to people.” from the report
Strong management improvements
The new manager had brought clearer leadership and better systems for finding and fixing problems.
“There was a new manager in post, who along with the provider's operations manager, had brought about clear leadership and an improved system to ensure people received good quality care.” from the report
Good partnership working
The home worked effectively with health and social care professionals, and acted on their advice.
“The staff team and manager are very good at getting in touch. Staff are knowledgeable and skilled to know when they need our advice.” from the report
Medicines records and storage
seriousA new pharmacy system meant some medicines stock records were inaccurate. Prescribed thickener was shared with people it was not prescribed for and was not always locked away. The manager addressed these issues during the inspection.
“We also saw that some staff were sharing a prescribed thickener with people for whom it had not been prescribed for and did not always make sure it was locked away after use.” from the report
One person's mealtime support
needs fixingMost mealtimes were well organised, but one person did not receive the support or equipment needed to make eating easier. The manager said this would be corrected and reviewed.
“We saw one person did not get the support they needed from staff or from equipment to make eating easier.” from the report
More detail for as-needed medicines
needs fixingInspectors asked the manager to add clearer instructions about what to do if as-needed medicines did not work, particularly when used for agitation. The manager agreed to do this immediately.
“We discussed with the manager about adding in more detail of what to do when these 'as and when' medicines were not effective” from the report
- 01What checks are now in place to make sure medicines stock records are accurate?
- 02How do you ensure prescribed thickener is only given to the right person and is locked away after use?
- 03What equipment and staff support will be provided if my relative needs help eating or drinking?
- 04What instructions do staff follow if an as-needed medicine does not work, especially if someone becomes agitated?
- 05How do you check that care plans remain up to date when a person's health or needs change?
This was an unannounced inspection of the overall service, including care, premises, records and all five CQC questions; the previous rating was Requires improvement in March 2018. This explanation was written from the published report of 16 March 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.
What inspectors found, March 2018
Rated Requires Improvement; inspectors found safe, kind care, but care records and checks on quality were not reliable enough.
This was an unannounced comprehensive inspection. The report gives the visit date as 23 January 2018 in its summary, but 25 January 2018 in the detailed inspection section. Inspectors spoke with people living in the home, visitors, staff, the registered manager and owners. They observed care and checked care records and management records.
People told inspectors they felt safe and well cared for. There were enough staff, medicines were generally given safely, the home was clean, and staff were kind and respectful. People also had access to activities and support from health professionals.
The home was rated Requires Improvement overall. Effective, Responsive and Well-led were also rated Requires Improvement. Care plans did not always reflect changes in people's needs, records about decision-making were not always clear, and quality checks had missed problems. The provider breached regulations about person-centred care and good governance.
Kind and respectful staff
People and visitors spoke positively about staff. Inspectors saw staff treating people patiently, respectfully and in a calm way.
“People were called by the name they preferred and were treated in a caring, respectful and friendly way.” from the report
Enough staff
Inspectors found staffing levels were sufficient and saw people receiving help promptly. Extra staff were used when people's needs increased.
“Throughout our inspection we saw that people received the support they required promptly because there were sufficient staff to care for people.” from the report
Safe and clean home
The home was clean and well maintained. Staff had safeguarding training, recruitment checks were completed and risks to people had been assessed.
“Communal areas and people's rooms were clean and hygienic.” from the report
Activities and links with others
People could join group and individual activities, go on trips and keep up previous interests. Staff also worked with health professionals to support people's wellbeing.
“Activities were on offer to keep people occupied both on a group and individual basis, and some of these were designed for people living with dementia in mind.” from the report
Care plans were out of date
seriousSome care plans and risk assessments did not reflect changes in people's needs, including falls, weight loss, continence and skin care. Information about behaviour that could challenge the service and end-of-life care also lacked detail.
“This meant we could not be sure the records were current and accurately reflected people's needs.” from the report
Quality checks missed problems
seriousAudits were in place but did not identify the issues inspectors found. There was no formal written development plan or clear system for monitoring actions.
“However these systems in place had failed to identify the issues and areas for improvement we found during our inspection.” from the report
Decision-making records were unclear
needs fixingThe home involved people who knew residents well in best-interest decisions, but records did not give enough information about people's capacity or any support they needed to make decisions.
“However we found very little information recorded about each person's capacity to make decisions or any support people may need to do this.” from the report
Food and snack arrangements
needs fixingMeals were closely spaced and inspectors recommended reviewing meal and snack arrangements, including more suitable nutritious options for individual dietary needs.
“We did note on the day of the inspection that the meals people were offered were closely spaced together.” from the report
Restricted toilet access
needs fixingBoth downstairs toilets were behind locked keypad doors. Inspectors said this could reduce independence and be undignified. The provider discussed plans to change this.
“This meant that access was restricted and staff had to take people to the toilet.” from the report
Unused medicines not securely stored
needs fixingMedicines waiting to be returned to the pharmacy were not held securely. The controlled drugs cabinet was also in a cupboard containing unrelated items.
“We discussed the storage of medicines with the registered manager as we found that those medicines waiting to be returned to the pharmacy were not held securely.” from the report
- 01How have you made sure care plans are now updated promptly after falls, weight loss, changes in continence or changes in behaviour?
- 02What written plan do you now use to monitor improvements and make sure audits identify problems?
- 03How are people's capacity assessments, best-interest decisions and Lasting Power of Attorney details recorded?
- 04What has changed about access to the downstairs toilets and the timing of meals, drinks and snacks?
- 05How are unused medicines stored securely while they are waiting to be returned to the pharmacy?
This was an unannounced comprehensive inspection covering all five questions, with the report giving different visit dates in its summary and detailed inspection sections. This explanation was written from the published report of 9 March 2018 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 Limited
3 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 14 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.
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