Bethany House Care Home

At this assessment we found 3 breaches of the legal regulations in relation to Premises and equipment, Good Governance and Staffing.

This assessment was undertaken due to the service having an aged rating. As part of the assessment, we spoke with people, relatives, care and housekeeping staff, professionals, registered manager, deputy manager and the nominated individual (The nominated individual is the person responsible for supervising the management of the regulated activity, ensuring the organisation meets its governance obligations, and supporting the registered manager).

The environment was not well maintained, and we found several areas to be in a state of disrepair. This included evidence of poor flooring in some people’s bedrooms and communal hallways, chipped furniture, rusted equipment, cracks in walls and damaged seals in bathroom, wet room and en-suite areas.

The provider did not have effective governance systems in place to monitor and improve the quality of the service. Some care plans lacked important information about people’s needs. Accurate records about the care people received were not always maintained or they contained conflicting information.

For people who had restrictions in place, we found that Best Interest Decisions were not always carried out in accordance with the Mental Capacity Act 2005. For example, best interest records were insufficiently detailed to demonstrate people were always protected and empowered to make their own decisions.

The service did not have effective systems or processes in place to assess safe staffing levels. Staff recruitment processes were not robust with evidence that one staff member had been employed with minimal checks undertaken. We also found evidence of gaps in staff learning and one to one supervision.

People spoke positively about the food and people’s weight was generally stable. There was evidence that the provider and staff worked closely with other stakeholders to meet people’s needs. Staff knew people well and were able to identify changes in their health and make appropriate referrals.

People spoke highly of the staff team, and we observed kind and caring interactions between staff and people.

We asked the provider for an action plan in response to the concerns found at this assessment.