Archived: Bethrey House

Updated 24 February 2023

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 Health and Social Care Act 2008.

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

This inspection was carried out by two 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.

Service and service type

Bethrey House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

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. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 12 people about their experience of care and 2 relatives. We observed people receiving care. We also spoke with 5 staff which included the registered manager, deputy manager and care staff. We reviewed a range of records. This included 5 people's care records and multiple medication records. We looked at 2 staff files in relation to recruitment. A variety of records relating to the management of the service, including medicine audits, care plan audits and the training matrix were also reviewed.

Updated 24 February 2023

Bethrey House is a residential care home providing personal and nursing care to up to 19 people. The service supports older people some of whom were living with dementia and mental health issues and younger adults. At the time of our inspection there were 17 people using the service.

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

Systems and processes in place to check the quality of the service people received were not consistently identifying areas for improvement. For example, care records had entries which were not appropriately described by staff, some records of interviews for staff vacancies were not on file and some care plans lacked detail. The registered manager understood their responsibilities for managing the home and ensured they followed duty of candour. The provider worked in partnership with other agencies and involved people, relatives and staff in the service.

People were safeguarded from abuse by staff who understood how to recognise the signs and report any concerns. Risks to people’s safety were assessed and plans put in place to reduce them. People were supported by enough staff to meet their needs. People were supported by staff who understood how to protect them from risks related to the spread of infection. Any incidents were investigated, and learning shared to reduce the risk of reoccurrence.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection

The last rating for this service was requires improvement (4 February 2021)

Why we inspected

We received concerns in relation to the management of the service and people’s safety. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bethrey House on our website at www.cqc.org.uk.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection. However, we have found evidence that the provider needs to make some improvements. Please see the well-led sections of this full report.

Recommendations

We have made a recommendation about window restrictors.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.