CQC report explained · a nursing home
What the CQC found at Bethshan Nursing Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection prevention and control procedures were being followed. They found arrangements for PPE, testing, safe admissions, cleaning, isolation and managing outbreaks.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, December 2020
Bethshan Nursing Home Limited was inspected but not rated; inspectors were assured that infection control measures were being followed.
This was an unannounced, targeted inspection on 12 November 2020. It followed concerns about infection prevention and control. Inspectors looked only at the measures in place to prevent and manage infection.
Inspectors found good practice in the use of personal protective equipment, staff training, cleaning, testing, isolation and social distancing. They were also assured that people were admitted safely and that visitors were prevented from spreading infection.
The home was inspected but not rated overall, and Safe was also marked inspected but not rated. This means the visit did not provide a new quality rating.
Staff infection control training
Staff had received infection prevention and control training and were supported to update their knowledge. Inspectors found that staff understood which protective equipment to use.
“Staff had received infection prevention and control training (IPC) and were regularly supported to update their knowledge and skills in relation to best practice standards.” from the report
Safe visiting arrangements
The home created a visiting pod so people could keep contact with family and friends while shielding or isolating. It included heating, a nurse call bell, phone and internet access, and a divider.
“The pod resembled a summer house, had insulation, safe means of heating (cool touch panels), a nurse call bell for assistance, phone and internet connection.” from the report
Cleaning and hygiene
Inspectors found the environment clean and saw that domestic workers understood cleaning and decontamination practices. Each unit had a designated cleaner.
“The environment was clean and domestic workers demonstrated good understanding of best practice standards for cleaning and decontamination.” from the report
Admission and isolation controls
People were tested before admission and asked to isolate for 14 days, even after a negative result. The home also used zoned isolation areas and separate staff arrangements.
“People were tested for Covid-19 before admission and asked to isolate for a period of 14 days, even if the test result was negative.” from the report
Inspectors raised no specific concerns in this report.
- 01How are staff currently trained and supported to keep their infection prevention and control knowledge up to date?
- 02How are visitors managed, and is the visiting pod or another arrangement available when people need to isolate?
- 03What testing and isolation arrangements are used for new admissions?
- 04How are cleaning responsibilities divided between units, and how is cleaning quality checked?
- 05What plans are in place if there is an infection outbreak?
This was an unannounced targeted inspection of infection prevention and control measures only, and the service was inspected but not rated. This explanation was written from the published report of 9 December 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, May 2018
Bethshan Nursing Home Limited was rated Good; inspectors found safe, kind and responsive care, with staffing recently increased to meet changing needs.
The inspection was unannounced and took place on 4 April 2018. Inspectors spoke with people living in the home, relatives, staff and visiting health professionals. They reviewed care records, recruitment files, staff rotas, training records, maintenance information and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff during the visit, safe medicines practice, suitable training, good care planning and prompt access to health professionals. People and relatives described staff as kind and caring.
The home had activities, community trips and support for people's personal choices. Inspectors also found that complaints were recorded and acted on, and that the provider and manager used audits and people's feedback to make improvements. The Good rating continued from the previous inspection in September 2015.
Prompt staffing support
Inspectors saw enough staff working during the visit. Call bells were answered promptly and staffing had been reorganised to provide more help at busier times.
“Call bells were answered promptly to ensure people received timely intervention and support with their needs.” from the report
Safe medicines and risk management
Medicines were stored securely and staff were trained to support people to take them safely. Personal risks and emergency evacuation needs were recorded and reviewed.
“People received the support they required to take their medicines as their doctors had prescribed.” from the report
Kind and respectful care
Staff knew people well, noticed when they were anxious or unwell and supported their privacy, dignity and independence.
“Throughout our inspection the staff were very attentive to people and treated people in a caring and respectful way.” from the report
Good activities and choices
People could choose where to spend their time and take part in activities such as baking, music, outings, church services and pamper sessions. People staying in their rooms were offered one-to-one support.
“We saw that there was a full range of activities for people to take part in.” from the report
Responsive care planning
Care plans covered physical, emotional, psychological and social needs. They were reviewed when people's needs changed, and relatives were involved in planning care.
“These plans had been reviewed as people's needs changed to ensure they remained accurate and gave the staff up to date information.” from the report
Active quality checks
The provider and manager regularly checked medicines, care records, nutrition, accidents, incidents and call bell response times. Improvements had been made to the building and staffing arrangements.
“Records showed audits were carried out regularly and updated as required in order to monitor the care and support provided by the home.” from the report
Inspectors raised no specific concerns in this report.
- 01How many staff are currently on each floor at the busiest times, and how are staffing levels changed when people's needs increase?
- 02How often will my relative's care plan be reviewed, and how will you tell us when their needs or health change?
- 03How do you check that medicines are given safely and on time, especially if my relative cannot clearly communicate?
- 04If my relative needs urgent hospital discharge support or specialist healthcare, how will the home arrange follow-up care?
- 05What activities and one-to-one support would be available if my relative preferred to stay in their bedroom?
This was an unannounced inspection of the overall service and all five CQC questions; the Good ratings continued from the previous inspection on 14 September 2015. This explanation was written from the published report of 2 May 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 Bethshan Nursing Home Limited
2 rated inspections over 3 years: the service has held its Good rating throughout.
- December 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Bethshan Nursing Home Limited →
- May 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Bethshan Nursing Home Limited →
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- September 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.
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