CQC report explained · a residential care home
What the CQC found at Bethel/Bethesda Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Risk assessments, safety checks, staffing, recruitment, infection control and medicines systems had improved.
- Effective?
- Requires improvement
- People generally received suitable care, training, food and healthcare support. However, some best-interest decisions had not been reviewed for over a year, and further improvements to the building were needed.
- Caring?
- Good
- Staff were kind, respectful and compassionate. People were offered choices, and their privacy, dignity and independence were supported.
- Responsive?
- Good
- Care plans had been updated and reflected people's preferences. Staff knew people well, responded promptly to call bells and supported relationships, activities and communication.
- Well-led?
- Good
- There had been a change of management and new quality checks and policies were introduced. The manager identified improvements and took action or made plans to address them.
What inspectors found, December 2021
Bethel/Bethesda Residential Home is now rated Good after improving from Inadequate and leaving special measures, but Effective requires improvement.
This was an unannounced follow-up inspection on 29 November 2021. One inspector spoke with people, staff and relatives, observed care, and checked care, medicines, recruitment and management records.
The inspectors found major improvements in safety, infection control, staffing, medicines and the way people were treated. People were supported with their choices, personal care, meals, healthcare and activities. The home was clean and visits were managed safely.
The Effective rating was Requires Improvement. Some best-interest decisions had not been reviewed for over a year, and parts of the building still needed refurbishment. The overall rating changed from Inadequate to Good, and the home was no longer in special measures.
Improved safety
The home had improved its risk assessments, emergency plans, call bell system and physical safety. Unsafe equipment had been replaced.
“Significant improvements had been made to the environment to make it safe.” from the report
Infection control
Staff used protective equipment correctly and the home followed infection control procedures. Visits were managed safely.
“Staff were observed to wear the correct personal protective equipment throughout our inspection.” from the report
Medicines
Medicines were given on time and as prescribed by staff described as competent and knowledgeable. Records and storage were checked and found to be safe.
“People received their medicines as prescribed, on time and in the way they preferred by competent and knowledgeable staff.” from the report
Kind and respectful care
Staff respected people's privacy and choices and supported their independence.
“We observed staff knocking on people's bedroom doors and seeking permission to enter.” from the report
Personalised support
Care plans included people's preferences and needs. Staff had time to spend with people and knew them well.
“People were supported by a consistent team of staff that knew them well.” from the report
Further refurbishment needed
needs fixingSome communal flooring, bedrooms, en-suites and furniture still needed improvement. A secure garden and dementia garden were planned but were not yet available.
“However, further improvements to the environment were required.” from the report
Some reviews overdue
needs fixingSome best-interest decisions had not been reviewed for more than a year. The manager said reviews were under way.
“We found some had not been reviewed for over a year.” from the report
Cleaning records
minorAudits had not identified gaps in weekend cleaning records, although the inspectors were assured that cleaning had taken place. The manager took immediate action to improve the recording.
“Audits had not identified gaps in the completion of cleaning schedules at weekends.” from the report
- 01Which refurbishment work is still outstanding, and what are the current timescales for the flooring, bedrooms, en-suites and furniture?
- 02Has the planned secure garden and dementia garden been completed, and how can residents use outdoor space now?
- 03Which best-interest decisions had not been reviewed for over a year, and have all of these reviews now been completed?
- 04Has an activities co-ordinator been recruited, and what activities are now available for people with different interests and abilities?
- 05How are weekend cleaning checks and records being reviewed since the issue identified by inspectors?
This was an unannounced follow-up inspection of all five key questions, including infection control, after the previous Inadequate rating and regulatory breaches. This explanation was written from the published report of 21 December 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, August 2021
Rated Inadequate and placed in special measures; inspectors found serious safety, care planning and leadership failures.
This was an unannounced, focused inspection on 2 June 2021. Inspectors looked at Safe, Responsive and Well-led, including infection control during COVID-19. They spoke with people, relatives, staff and a health professional, and reviewed care, medicines and management records.
The home was rated Inadequate overall. Safe, Responsive and Well-led were all rated Inadequate. Inspectors found that some people were at risk because their needs and risks had not been assessed, staff did not use PPE properly, faulty equipment was used and parts of the building were unsafe.
Care was not personalised or planned with people and their relatives. Activities were not regular, some end of life plans were missing and complaints were not clearly tracked. Leaders did not have effective oversight or systems to identify and fix problems.
The previous overall rating was Good, published in June 2019. The home was placed in special measures, with CQC saying it would monitor progress and re-inspect, normally within six months.
Contact with relatives
People were supported to telephone relatives during the pandemic, and visiting arrangements were in place.
“People were supported to contact their relatives through the COVID-19 pandemic.” from the report
Working with health professionals
Staff contacted health professionals when needed, and relatives said this was done in a timely way.
“Relatives told us the service contacted the GP and other health professionals in a timely manner if it was required.” from the report
Recording medicines
For the medicine records reviewed, staff recorded medicines when they administered them and recorded a refusal followed by contact with the GP.
“Staff completed MARs when they administered medicines.” from the report
COVID-19 infection control
seriousStaff, including senior staff, were seen without the required PPE and did not always know when or how to use it. Some staff had not received PPE training.
“This placed people living at the service at significant risk of contracting and transmitting COVID-19 and other viruses.” from the report
Missing risk assessments
seriousSix of the 12 care records reviewed had no care plans or risk assessments. Some plans had not been reviewed for many months.
“We reviewed 12 people's care plans and risk assessments and found six people had no care plans or risk assessments in place.” from the report
Unsafe equipment and building
seriousA wheelchair wheel fell apart while being used. Inspectors also found damaged floors and carpets, unlocked external doors and unsafe areas that people could access.
“Staff failed to assess equipment before it was used placing people at serious risk of harm and injury.” from the report
Personalised care
needs fixingPeople and relatives were not involved in care planning. Plans did not cover important individual information such as religion or sexual orientation.
“People were not receiving personalised care.” from the report
Limited activities
needs fixingActivities were not offered daily or regularly. Some people were mostly in their bedrooms or lounge areas, and one person was described as lonely.
“While this demonstrated activities were offered, it was not on a daily or regular basis.” from the report
Weak leadership and monitoring
seriousLeaders did not have a clear view of day-to-day practice. Systems to identify problems, support staff and improve care were not robust or consistently in place.
“Processes and systems were not robust or in place to identify areas that needed improvement, and to affect change to improve the quality of care people received.” from the report
- 01What changes have been made to ensure every person has a current care plan and risk assessment?
- 02How do you now check that all staff use PPE correctly and have completed relevant infection control training?
- 03What repairs and equipment safety checks have been completed since this inspection?
- 04How are people and their relatives involved in writing and reviewing personalised care plans?
- 05What was the outcome of the special measures monitoring and any later CQC re-inspection?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward when calculating the overall rating. 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 Bethel/Bethesda Residential Home
9 rated inspections over 7 years: the service has held its Good rating throughout.
- December 2021Goodcurrent ratingup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Bethel/Bethesda Residential Home →
- August 2021Inadequatedown from GoodSafe: InadequateResponsive: InadequateWell-led: Inadequate
Read what inspectors found at Bethel/Bethesda Residential Home →
- July 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2019Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- November 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Requires improvementstayed Requires improvementEffective: Requires improvement
- October 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 3 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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