Bethel/Bethesda Residential Home

Updated 21 December 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

Bethel/Bethesda Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

The registered manager was also the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection and sought feedback from the local authority. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection-

We spoke with three people who used the service about their experience of the care provided. We spoke with seven members of staff including the registered manager, senior care staff, care staff, kitchen staff and a housekeeper.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included three people’s care records and five people’s medicine records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data, quality assurance records, care records for one person and policies. We spoke with four relatives about their experience of the care provided and two care staff.

Updated 21 December 2021

About the service

Bethel/Bethesda Residential Home is a care home registered to provide accommodation and personal care for up to 34 older people. There were 20 people receiving care at the time of the inspection.

Bethel/Bethesda Residential Home provides care to people from one building, separated into two sides via a keypad entry system. One side of the service is known as Bethel, and the other Bethesda.

All people living at the service had their own bedrooms. Some bedrooms had en-suite facilities, others had sinks only. There was a bath/shower room, dining room and lounge area in each side of the service.

There was no garden at the service, but people could access the courtyard should they wish to spend time outdoors.

People’s experience of using this service and what we found

There had been a change of management since the last inspection. Significant improvements had been made to the safety of the service. The registered manager was passionate about improving the care people received at Bethel/Bethesda and had a good knowledge of the regulatory requirements. A refurbishment plan was underway to further improve the environment. Whilst improvements had been made, further improvements were required. People had been consulted about changes to the environment and had chosen new décor and furniture.

Policies and quality assurance systems had been implemented to enable the registered manager to monitor the quality and safety of the service. These had identified improvements needed and action had been taken to address these or was planned.

Infection prevention and control systems and processes had improved significantly. Staff were observed to wear the correct personal protective equipment throughout our inspection. The service was clean. Professional visitors were not permitted to enter the service unless they could evidence a negative lateral flow test and at least two doses of an approved COVID-19 vaccine. Visits were safely facilitated. Infection prevention and control policies were robust and followed.

There were enough staff to support people with their needs and staff had been safely recruited. They knew how to keep people safe from harm or abuse. Staff had a good knowledge of risks associated with providing people's care and received training relevant to people's needs. We received positive feedback from staff about the new training programme that had been implemented.

People received their medicines on time and as prescribed by skilled and competent staff. Medicines were safely stored.

The service supported people to express their views, preferences, wishes and choices. Staff supported people to engage in their hobbies and interests and promoted people's independence. Improvements were planned to provide more varied activities. People knew how to raise a concern or make a complaint and felt confident this would be addressed.

Staff were observed to deliver kind, compassionate and respectful care to people. People’s privacy and dignity was respected. We received positive feedback about the care staff and management team.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive ways possible; the policies and systems in the service supported this practice. People were supported to eat and drink enough and to attend healthcare appointments as needed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 25 August 2021) and there were four breaches of regulation. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 24 August 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

The overall rating for the service has changed from Inadequate to good. This is based on the findings at this inspection.

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.