Bethel House. Haven Care Centres Limited. Overall rating for this service. Inspection report. Ratings. Good

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1 Haven Care Centres Limited Bethel House Inspection report St Bees Road Whitehaven Cumbria CA28 9UB Tel: Date of inspection visit: 16 January 2017 Date of publication: 27 March 2017 Ratings Overall rating for this service Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led? 1 Bethel House Inspection report 27 March 2017

2 Summary of findings Overall summary This unannounced inspection took place on 16 January We last inspected Bethel House in January At that inspection we found that there were no breaches of regulation. At our previous inspection in January 2016 we found that the service had made significant improvements and been rated as required improvement overall. During this inspection we reviewed actions the provider had taken to continue to develop and improve the service. We found that improvements made had been maintained and that the service was being developed and improved. Bethel House is situated on the outskirts of Whitehaven. It is an older property that has been extensively adapted and extended to provide accommodation for up to 62 people who are living with dementia or other mental health needs. One part of the building provides nursing care. The home provides accommodation in 60 single rooms and two shared rooms with ensuite facilities. There are communal lounges and dining areas and secure garden areas for people to use. There is car parking for visitors and staff. At the time of the inspection there were 57 people living in the home. The service had a registered manager in post and they had been in post since April A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The registered manager had notified the CQC of any incidents and events as required by regulation. People who lived at Bethel House told us that they felt safe in the home and that there were staff available to help them when they needed this. They made positive comments about their home. They told us that care staff were available to help them when they needed assistance, respected their privacy and that staff "couldn't be nicer". People living and visiting the home spoke highly of the registered manager and told us they were happy with the care and treatment. We saw that the staff on duty approached people in a friendly and respectful way and everyone we spoke with told us that they felt safe living there and were "happy" and "being well looked after" living at the home. People had a choice of meals and drinks and they told us the food was "good" and that they enjoyed their meals. We looked at the way medicines were managed and handled in the home. We found that medicines were being safely stored and administered and records were being kept of the quantity of medicines kept in the home and those disposed of. Training records indicated that staff had received training on safeguarding people from abuse. The staff we spoke with knew the appropriate action to take if they believed someone was at risk of abuse and were aware of the procedures for reporting bad practice or 'whistle blowing 'within the organisation. We saw that the registered manager had followed the service's procedure promptly in regards to misconduct by a staff 2 Bethel House Inspection report 27 March 2017

3 member. They service had safe systems for the recruitment of staff to make sure the staff taken on were suited to working there. We saw that care staff had received induction training and on going training and development and had regular supervision and annual appraisal. The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves. Staff had completed a programme of induction training and there was programme of on going training for all staff. Staff told us how they felt supported through supervision and training to fulfil their roles. The level of staffing on the day of the inspection was sufficient to ensure that the current number of people living in the home had their needs met in a timely manner. The numbers of staff on shift during the day and night were seen to be consistent. Systems were in place for the continued recruitment of staff and to make sure the relevant checks were carried out before employment. We saw that there were systems in place to assess the quality of the services in the home. There was a programme in use to monitor or 'audit 'service provision to identify areas of weakness and address them. The service had worked with local GPs, district nurses, health care professionals and external agencies to provide appropriate and timely referrals to these services to meet people's different physical, psychological and emotional needs. There was a programme of organised activities for people to take part in if they wanted to. The activities programme was under review when we inspected so that people's individual needs, preferences and interests could be incorporated into it. We noted that care staff initiated impromptu activities when the opportunity presented itself to engage with people We observed there was limited signage on the residential unit, where people were living with dementia, to help them orientate themselves around the unit. We made a recommendation that the registered manager seek advice and guidance on how they could adapt the home's environment to facilitate as much as possible, the independence of the people living there with dementia. 3 Bethel House Inspection report 27 March 2017

4 The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? The service was safe. Records were kept of medicines received, used and disposed of so all could be accounted for. There were sufficient staff on duty to support people and staffing was being kept under review. Staff we spoke with in the home knew how to recognise possible abusive situations and how it should be reported. We saw that all the checks and information required by law had been obtained before staff had been offered employment in the home. Maintenance checks were being done regularly and records had been kept of these. Is the service effective? The service was effective. There was a programme of staff training and supervision in place to support staff development. People were having their individual needs and preferences assessed to promote their best interests in line with legislation. People reported the food was good. People had a choice of food at mealtimes and had a choice of meals, drinks and snacks. The environment was welcoming but could be further adapted to give more support to the independence of the people who were living with dementia. Is the service caring? The service was caring. People told us that they felt they were being well cared for and we saw that the staff were being respectful and polite in their 4 Bethel House Inspection report 27 March 2017

5 approaches. We saw that people were treated with respect and their privacy and dignity were being promoted. Staff demonstrated good knowledge about the people they were supporting, for example detailed information on their backgrounds, their likes and dislikes Is the service responsive? The service was responsive. We saw here were some organised activities for people if they wanted to take part. The programme was under review to improve the service provision. Support was provided to help people to maintain their relationships with friends and relatives. Information was displayed on how to make a complaint within the home. There was a system in place to receive and handle any complaints raised. Is the service well-led? The service was well led. People who lived in the home were asked for their views on how they wanted their home to be run and their comments were listened to. Quality audits were used to monitor care planning, medication management and service provision. Staff told us they felt well supported and listened to by the registered manager and senior staff 5 Bethel House Inspection report 27 March 2017

6 Bethel House Detailed findings Background to this inspection We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act This inspection took place on 16 January 2017 and was unannounced. The inspection team consisted of two adult social care inspectors and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. During the inspection we went around the home and looked at all areas used by the people living there. We spoke with fifteen people who lived there. We observed the care and support staff provided to people in the communal areas of the home and at meal times. We looked in detail at the care plans and records for seven people and tracked their care. We spoke with eight relatives who were visiting during the inspection and two visiting health care professionals. Some people living at the home could not easily give us their views and opinions about their care. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us better understand the experiences of people who could not easily talk with us. It is a useful tool to help us assess the quality of interactions between people who use a service and the staff who support them We spoke with six members of nursing and care staff, the registered manager, the deputy manager and the registered provider. We also spoke with maintenance, laundry, domestic, activities staff and the cook. We looked at records, medicines and care plans relating to the use of medicines in detail for people living in the home. We observed medicines being handled and discussed medicines handling with staff. We looked at medication and records for nine people living in the home at the time of the inspection. We looked at records that related to the maintenance of the premises, the management of the service and quality monitoring documents and records. We looked at the staff rotas for the previous month and at the recruitment records for seven staff working in the home. This included new staff. We looked at records of 6 Bethel House Inspection report 27 March 2017

7 staff training and supervision. 7 Bethel House Inspection report 27 March 2017

8 Is the service safe? Our findings We asked people who lived at Bethel House what it was like living there and if they felt safe living there. Comments we received from people who lived there included, "It's nice here, they are nice to me" and "There are plenty [staff] about to look after me and keep me safe and sound". Another person told us, "There seems to be enough of them [staff], you can always find one". The home's own satisfaction surveys asked people if they felt safe living at Bethel house. Everyone who had responded to the survey said they felt safe living there. Relatives told us, "There always seems enough staff on duty" and "We have never seen anything to worry us, you read such things in the papers but we are very happy that [relative] is safe here". Another relative commented, "There seems enough staff, but they are a bit short now and then mind" and "I have never seen anything to bother me". A relative said, "the staffing varies a bit, not so often now, just sometimes but you can always find someone. We are happy [relative] is safe here". We noted that doors to and from the units within the home had key code pads for security and visitors rang a bell and waited to be admitted. A member of care staff told us that the registered manager always assessed people's needs before they came to live in the home to make sure they could meet their needs. They told us the registered manager made sure admissions were staggered so staff were not "overloaded". Staff gave us examples of where the registered manager had not offered a place to someone whose high dependency was such that they felt staff would be unable to meet all their needs without affecting the care of other people. Staff told us that the registered manager was "Not scared to say we can't take someone because we can't meet their needs just now". Well planned admissions that take account of staffing levels help to make sure that staff will be available when people need them. We looked at the staff rotas for the previous three weeks and observed staff deployment during the inspection. There was an adequate level of staffing on both residential and nursing units during the day. Staff and the registered manager told us if they needed additional staff to support someone if their condition was deteriorating or for particular behaviours then staff could be called in. Staff told us that the registered manager would always come in if they needed them in an emergency. However, this arrangement for additional assistance was not a formal system. We discussed with the registered manager the levels of staffing at night in the event of an emergency should people with a high level of need to be moved. The levels of staffing were being kept under review as occupancy increased. The registered manager had long term plans to take on a new member of night staff to work between the residential and nursing units to give help where needed. The registered manager was introducing a dependency tool to help them in assessing and adjusting staffing levels against people's identified needs. This was being introduced and we were shown the document and the process for calculating the level of staffing that would help them on deciding upon their staffing levels. Staff were allocated their own small group of people living in the home to make sure they had their needs met and senior staff were responsible for monitoring and making sure record were properly completed. 8 Bethel House Inspection report 27 March 2017

9 There was an on call system to access management support during the night and outside normal working hours. The registered manager was continuing with the recruitment of nursing and care staff as the numbers of people living in the home increased. We saw safe recruitment procedures and checks were in place, in line with legislation, to help ensure staff were suitable for their roles. Staff told us they had received training in safeguarding adults and training records confirmed this. All the staff we spoke with knew the appropriate action to take if they believed someone was at risk of abuse. They were also aware of the procedures for reporting bad practice or 'whistle blowing 'within the organisation. All the staff we spoke with were confident that the registered manager would follow up any concerns they might raise and that prompt action would be taken to make sure people were kept safe. We noted during the inspection that contractual arrangements were in place for staff. These included disciplinary procedures to support the organisation in taking immediate action against staff in the event of any misconduct or failure to follow company policies and procedures. We noted the service had followed their procedure effectively in regards to misconduct by staff members. During this inspection we spent time in all areas of the home. We saw the environment was homely and comfortable. We looked around the home and saw that all areas were clean and fresh and we observed cleaners at work throughout the day. We saw that staff had easy access to protective equipment and we saw staff using this equipment appropriately when delivering care and at meals. The service had procedures and guidelines for staff to work to about managing infection control. The home had a laundry that was well away from areas used by people living in the home. However, we noted areas within the laundry that needed to be cleaned, including behind the washing machines and under the containers on linen trolleys. We spoke with registered manager about this and they took action during the inspection to ensure the laundry was thoroughly cleaned. The laundry was in the basement of the home and was not an ideal location. However, the registered provider had taken steps to try to mitigate the problems. The floor had been painted to make it easier to keep clean and there were separated areas for dirty and clean linen to have a 'flow through' system to help reduce the risks of cross infection. The moving and handling equipment we saw in use, such as hoists, were clean and were being maintained. Records indicated that the equipment in use in the home had been serviced and maintained under contract agreements and that people had been assessed for its safe use. The records showed safety checks and servicing in the home was being done including the emergency equipment, water temperatures, fire alarm, call bells and electrical systems testing. Maintenance checks were being done regularly and records had been kept. These measures helped to make sure people were cared for in a safe and well maintained environment. We saw the service had contingency plans in place in the event of foreseeable emergencies and should people ever need to be moved to a safer area in the event of an emergency. We saw there were clear notices within the premises for fire procedures and fire exits were clear. We observed staff transferring people in and out of wheelchairs appropriately and people were given quiet repeated directions to transfer safely. Wheelchairs had lap straps where appropriate and footrests were in place. Risks to people's individual safety and well-being were assessed and managed by means of individual risk 9 Bethel House Inspection report 27 March 2017

10 assessments and risk management strategies. This helped ensure guidance was in place for staff on minimising risks to people's wellbeing and safety. Everyone had individualised risk assessments in their care files covering areas such as, mobility, personal care, mental health, risks of choking, nutrition, falls, the use of bed rails and moving and handling. Each risk assessment offered an overview of the person's risk, triggers and the assistance they required. The service used a monitored dose system for medicines and had just changed their supplying pharmacy. The new pharmacy had provided training and support to staff on the new systems We looked at the way medicines were being managed and handled in the home. We found that medicines were being safely administered and records were kept of the quantity of medicines kept in the home. We counted a sample of six medicines on the nursing unit, compared them against the records, and found the medicines tallied. Training records indicated that staff who carried out medicines administration had received training in line with the registered provider's medication policy. We looked at the handling of medicines liable to misuse, called controlled drugs. These were being stored, administered and recorded correctly. Refrigerator temperatures were monitored and the records showed that medicines were stored within the recommended temperature ranges to help prevent any deterioration of the medicines. We saw there were protocols for giving 'as required' medicines and when these medicines had been given, it had been clearly recorded. This helped to make sure that people received the medicines they needed appropriately. We found that regular audits and stock checks were being done and administration procedures were being monitored 10 Bethel House Inspection report 27 March 2017

11 Is the service effective? Our findings We spoke with people on both the nursing and the residential unit. On the residential unit we received positive comments about the food provided were told "I think we are well looked after, we always get plenty to eat" and "The food has been quite good up to press, quite a bit of choice". We observed the lunch time meal on the residential unit and the nursing unit and received positive comments including, "I like it [the food], it was a very nice lunch" and "You get a drink every two minutes and the food is OK". A visiting relative told us, "The girls have been wonderful they have worked really hard on [relative] legs and they are so much better, the district nurse and the GP comes in and they are very pleased with her". Two other visitors we spoke with told us "the staff seem well trained". A relative said, "[relative] has been losing weight but it's not the girls'[staff] fault, they are investigating as there is something else going on. They have had the nutritionist in and [relative] is on a pureed diet and that is beautifully presented and she really enjoys it". We saw that people's care plans had nutritional risk assessments in place and for specific dietary needs. We saw that people had their weight monitored for changes so action could be taken if needed. Where needed the dietician and the speech and language therapist (SALT) had been involved to advise on dietary management plans for people. The cook was aware of the special dietary needs of people in the home such as purred diets and those people requiring thickeners in liquids. We noted that staff offered people aprons at mealtimes. "Would you like an apron, just to keep your lovely clothes clean"? We saw that staff would bring the alternative meal choices plated and ask each person which they preferred. The meals looked appetising, there were good portions on each plate, and from the relaxed atmosphere people were clearly enjoying their food. Some people had both meals and parts of each and were offered seconds, puddings and cake or yoghurt. Meals that were being taken out to people in their rooms were placed on trays and taken out covered. Staff sat with people who needed some help to have their meal and encouraged them to finish meals and drinks. We noted that drinks were offered in white mugs or smaller cups, whichever people said they preferred and some used adapted cups to help them take their drinks themselves. CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act 2005 (MCA).The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are 11 Bethel House Inspection report 27 March 2017

12 called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and whether any conditions on authorisations to deprive a person of their liberty were being met. At this inspection we looked at people's records and saw that the registered manager had applied to relevant supervisory authorities for deprivation of liberty authorisations for people. These authorisations had been requested when it had been necessary to restrict people for their own safety and these were as least restrictive as possible. We saw that people who had capacity to make decisions about their care and treatment had been supported to do so. We saw this in people's involvement in making decisions about 'do not attempt cardio pulmonary resuscitation' (DNACPR) for their future care and their emergency health care plans (EHCP). Some people were not able to make some important decisions about their care or lives due to living with dementia. The records in place showed that the principles of the MCA were being used when assessing a person's ability to make a particular decision. This helped to make sure that any decisions that needed to be taken on a person's behalf were only made in their best interests. Staff had received training on the MCA and those we spoke with understood the principles of the act. We noted that the information around who held Power of Attorney [POA] for a person was not being made clear in care plans so all staff knew who had this in place for contact if needed. We discussed this with the registered manager. The registered manager was aware who had a power of attorney in place. They confirmed to us this information would now be routinely included in people's care plans so all other staff would have the information as well. Powers of Attorney show who has legal authority to make decisions on a person's behalf when they cannot do so themselves and may be for financial and/or care and welfare needs. We looked at staff training and development records and spoke with staff about their training and the supervision and support they received. Staff we spoke with told us "Training has been good" and "I have supervision and [registered manager] is aware of my training needs and what I need to develop on my job". We spoke with senior care staff who confirmed that before taking up their senior roles that had received additional training including on developing supervisory skills and care planning to support them in their new role. We could see from records and from speaking with staff that they had undertaken training that the registered provider considered essential for their roles. This included moving and handling, safeguarding people, medicines management, first aid, infection control, fire training. Staff had received dementia care awareness training to help them understand the condition and to support people living with this. The training matrix indicated that training provision was monitored and was being booked in advance throughout the year to keep people up to date. The service had trained two members of staff as moving and handling trainers. This helped to make sure that staff had prompt access to training and advice on this topic. We saw an example of where care staff had received additional training to be able to provide support for a specific aspect of care for one person. We also saw that professionals were being involved in providing training and information to staff. The speech and language therapist was due to come in to the home to speak with staff about their role and issues around swallowing or choking risks. The Tissue Viability Nurse (TVN) was also coming to provide some training and information to update nursing staff and increase care staff awareness. Capital expenditure planning was in place for service to improve the environment or people living at the 12 Bethel House Inspection report 27 March 2017

13 home. This had been continuing since our last inspection in January The work included new furniture to meet people's individual needs, a new conservatory on the residential unit and a programme of redecoration for rooms as they became vacant. The conservatory on the nursing unit was being redecorated and a new floor being laid. New furniture was on order for the room and the registered manager intended to extend the rooms use for social events. We noted on the residential unit that some corridors had some tactile panels and there were two 'handles and locks' boards to engage people but there was limited signage on the residential unit, where people were living with dementia, to help them orientate themselves around the unit. We noted that corridors and bedroom doors were very alike. Research and current good practice in dementia care (for example, Department of Health National Dementia Strategy, Kings Fund) highlight that attention needs to be given to establishing environments that enable people who are living with dementia to find their way around independently. For example, clear signs (using pictures and words) help enable people living with dementia to move around more confidently. Items like memory boxes for people to fill with personal items can help them to navigate to their rooms. The registered manager told us they had plans to develop different areas in the home to make them more 'dementia friendly'. We recommend that the registered manager seek advice and guidance from a reputable source on how they can continue to adapt the home's environment in line with good practice to support, as much as possible, the independence of the people living there with dementia. 13 Bethel House Inspection report 27 March 2017

14 Is the service caring? Our findings We spoke with people living at Bethel House about how they were cared for and how staff supported them to live as they wanted. People we spoke with made some positive comments about the staff that supported them. We were told, "It's nice here, they are nice to me" and "The girls take care of me, they couldn't be nicer". We were also told, "It's nice enough, the girls are nice, they look after me" and "Everyone is friendly here, we have a good laugh". Relatives we spoke with during the inspection made positive comments about the care and support their family members received. Comments made to us included, "The staff have been wonderful to [relative], they came out of hospital and went to another home but didn't settle. She came here and settled right away" and "The staff are so kind to (relative)" and "They always speak to us and offer us a cup of tea, we can come when we want". Another relative told us, "The girls are marvellous. I cannot fault them. I come in every day so I have seen the changes, it is much improved". We were also told by another relative, "The care has been very good, the girls are lovely to (relative), she gets a cuddle and everything, I can't fault that. We can come when we want, we get offered a cup of tea, the girls are so good". Relatives of people who lived at Bethel House told us they could visit anytime of the day or week, there were no restrictions and they felt welcomed. This meant that people were able to continue maintaining important relationship in their lives. A relative told us, "They [staff] treat them [relative] like family. I am very happy and confident with the care of [relative]". We observed that people living in the home were well presented. Ladies were often in coordinating clothes, had their handbags with them and had stockings or socks on with their slippers or shoes. We saw that staff respected people's privacy. We observed that doors to bathrooms and toilets were kept closed when in use and bedroom doors closed whilst personal care was being given. We spent time in different communal areas of the home throughout the inspection we saw that the staff took up opportunities to engage positively with people and we saw people enjoyed talking with the staff. We used the Short Observational Framework for inspection, (SOFI) to observe how people in the home were being supported and were spending their time. We observed staff on both nursing and residential units constantly moving from room to room around the unit checking on and engaging with people. Staff at the home communicated well with the people who lived there and gave people the time they needed to express their wishes. We saw several pleasant interactions taking place between staff and service users with appropriate hugs. We noted that there were displays of obvious affection between staff and the people they were caring for. Staff knew about the people they were supporting well and their life histories and were able to use this in their conversations. We observed occasions when staff reacted quickly and discreetly to assist people and guide them to their rooms for assistance with personal care. We saw that staff were respectful and asked people politely about helping them. We heard staff ask "Shall we go to your room and get changed" and "Would you like a shave, shall I come with you. With the person's agreement, they went to do this with them. We observed that staff 14 Bethel House Inspection report 27 March 2017

15 phrased their questions to people as requests, for example "would you like to"' or "shall we" and "Can we do this". We noted staff encouraging and helping people to wash their hands at lunchtime. We saw this was done respectfully and with explanation, "I am just going to give your hands a wipe, is that alright"? With the persons agreement they explained what they were doing with each hand. The service had access to advocacy services that people could use if they wished to. An advocate is a person who is independent of the home and who can come into the home to support a person to share their views and wishes if they want or need this. 15 Bethel House Inspection report 27 March 2017

16 Is the service responsive? Our findings We asked people who lived in the home and their relatives if they were involved in developing the care plans. Some people could not tell us about this but their relatives told us that they had been involved in helping to develop their care plans and involved in reviews of care reviews. A relative told us "We do the reviews and things with them and they [staff] tell us about everything we need to know" and "We do the care plans with staff". Another relative said, We are their next of kin and have power of attorney so we do all the paperwork and such for them". Staff working in the home told us that the registered manager had made sure that families were "much more involved" in people's care and what went on in the home. There was a list of activities on the wall of the residential unit. There were group activities such as dominoes, quizzes, painting, singing, colouring, jigsaws and reminiscence. On the day of the inspection, dominoes and hand ball games were on the programme. We noted that a member of care staff was leading a dominoes session during the morning in the sitting room of the residential unit with five people who had chosen to take part. The advertised activities did not make reference to regular church services or church visits. We asked people who lived in the home about what activities there were for them to take part in if they wanted. On person told us," There is not much to do really, sometimes there is, but not much." Others told us, "We would like something to do sometimes, we just have to sit" and "Nothing to do though, I get bored out of my mind". One person who lived there told us "They won't let me do anything you know, but I could still work and do things". They went away to talk to the cleaner about cleaning. Later we noted a care worker went to lay the tables with cloths and cutlery for lunch. This was a meaningful activity the person we had spoken with could have assisted with to help them feel involved and useful but they were not asked. Another person was standing by the internal doors and told us "I'd like to go out; I would like to go for a walk". However, there was no staff or activities person to help them to go out safely. The residential unit had a little dog that belonged to a person who lived there, this was on a trial basis, but people who lived there appeared to like 'George' the dog.one person who lived there said "That's a little dog, but it's no bother." In the quiet room, one person pointed out to us a budgerigar in a cage. They person was sat next to the cage and told us "He's called Gary, he is lovely." A relative told us "I bring ferrets in every now and then, so everyone can hold them, they like that. I fetch the whippet as well." We noted that the satisfaction survey completed by people living in the home had indicated that some people were unaware of what the activities were. The registered manager had begun the work to address this and there were activities calendars on both the units for people living there and relatives for reference. The registered manager had already recruited one activities coordinator and at the time of the inspection had just recruited another. These posts were to help facilitate group and individual activities over a seven day period. The newly recruited coordinator was qualified to drive the service's minibus so should be able to introduce more outings into the activities programme. The activities programme was currently under review when we inspected so that people's individual needs, preferences and interests could be incorporated into 16 Bethel House Inspection report 27 March 2017

17 it. We noted that care staff initiated impromptu activities when the opportunity presented itself to engage with people, such as singing, reminiscing and board games. Care plans we looked at this inspection showed that assessments of individual needs and risks had been done to identify people's care and support needs. We saw that everyone had a health passport with important information about them should they need to go to hospital. In all the care plans we looked at we saw there were risk assessments in place that identified actual and potential risks and had the control measures to help minimise them. We noted in one person's care plan that the monthly care review was overdue, as it had not been done the previous month. However, this was not the case for the other care plans we looked at and raised it with the registered manager to follow up with staff. Information on people's preferred social, recreational and religious preferences were recorded in individual care plans. This helped to give staff a more complete picture of the individuals they were supporting. Staff we spoke with did know about the individuals they cared for and what mattered to them. Staff we spoke with had a good understanding of people's backgrounds and lives and this helped them to give support and be more aware of things that might cause people anxiety. The care plans and records that we looked at showed that people were being seen by appropriate professionals to meet their needs. For example, referrals had been made in a timely way to the dietician and speech and language therapist. Advice had also been taken from the community mental health team and the learning disability team on managing mental health needs. The information and advice given had been incorporated into care plans so staff knew what the person needed to support them. Visiting healthcare professionals we spoke with during the inspection said that communication had improved We reviewed how the service responded to complaints. We looked at the policies and procedures along with information provided to people who used the service complaints recorded since our last inspection. We looked at these and found formal complaints had all been recorded and responded to in line with the policies and procedures of Bethel House. Relatives told us that they knew who the registered manager and deputy manager were and saw them around the home when they visited. They said they felt they could speak with either at any time to raise any matter of concern. 17 Bethel House Inspection report 27 March 2017

18 Is the service well-led? Our findings People who lived in the home said they felt involved in the way the home was run and got a chance to give their views. We looked at the minutes of the 'resident's meetings' that are scheduled for six monthly intervals and also the results of the home's last satisfaction surveys. The survey responses returned from people living in the home and their relatives were positive. We saw during our inspection that the registered and deputy manager spent time with the people who lived in the home on the different units and engaged in a positive and informal way with them. The home had a registered manager in place as required by their registration with the Care Quality Commission (CQC). All the staff we spoke with told us that they were well supported in the home and felt that they could speak with the registered manager or supervisors at any time. They said they had regular meetings and individual supervision to discuss practices, share ideas, any problems and any areas for development. Staff spoke well of the management team in the home and felt that all the staff in the home worked well together and were "a good team". We noted that the registered manager had worked with staff on both day and night duty and had done spot checks on nights shifts to monitor workload and activity.. Staff expressed confidence in the registered manager. We were told, "She is spot on" and also "She has made improvements everywhere in the home, she has really pulled this home up". We were also told by staff members that the registered manager "Sets very high standards" and "Will work alongside us and knows what happens on the floor". A member of staff told us, "You remember what it was like before we had a new manager. I didn't know whether I was coming or going, it's been a hard slog but we are getting there. It has been worthwhile now you can see the improvements and the things that are planned; it has to be so much better for everyone, staff and residents". The registered manager had systems in place to assess the quality of the services in the home and to review the policies and procedures in use in the home. We saw the quality monitoring systems were being effective in identifying areas that required further improvement. We saw that when identified action had been taken to make any changes required such as with the medication system, care planning and infection control. We saw that audits had been done on care plans and medication records on a monthly basis and there was also a weekly stock check of medicines. Actions arising from the previous audit were monitored for follow up. We also saw that nursing and senior care staff involved in medication administration had done medication training to make sure their practices were safe. This quality monitoring helped to make sure people received the right treatment and support and that any errors or omissions were noticed and dealt with promptly. The registered manager was the lead on infection control for the service and had begun to carry out audits on this. They had identified some hand hygiene issues that had been addressed through training and observations. Maintenance checks were being done regularly by staff and records kept. There were cleaning records to help make sure the premises and equipment were being kept clean and safe to use. There were systems in place for reporting incidents, falls and accidents in the home that affected the people living there. We saw that these were being followed and if required CQC had been notified of any incidents 18 Bethel House Inspection report 27 March 2017

19 and accidents and when safeguarding referrals had been made to the local authority. We saw that the registered manager made regular checks on the premises and environment. They had identified some areas that needed attention and we saw these were being addressed in a systematic way. The service worked with local GPs, district nurses and health care professionals and external agencies to provide appropriate care to meet people's different physical, psychological and emotional needs. The service worked with local GPs, district nurses and health care professionals and external specialists. We had received positive feedback from service commissioners, social services and healthcare professionals that improvements made within the service were being maintained by the management team 19 Bethel House Inspection report 27 March 2017