Archived: Bevan House

Updated 10 August 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked 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 2014.

This inspection took place on 15 June 2015 and was unannounced. The inspection was carried out by an adult social care lead inspector.

During the inspection we spoke with eight people who lived in the home, two relatives, four of the care staff, a member of the domestic staff, the supervisor on duty and a registered manager from another of the registered provider’s homes who was supporting the new manager. The new manager was not on duty on the day of the inspection.

We observed staff as they went about their duties and interacted with people and supported people in the communal areas of the home. We spoke to people alone and in groups, in private and communal areas. We also spent time looking at records, including looking in detail at seven people’s care plans and risk assessments. We did this to help us see how their care was being planned with them and delivered. We also looked at the staff rotas for the previous two months, staff training and supervision records.

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 to us.

We looked a sample of the records relating to the maintenance and management of the service and records of checks being done on how quality of the service provision was being monitored. As part of the inspection we also looked at records and care plans relating to the use of medicines.

Before our inspection we reviewed the information we held about the service. We looked at the information we held about notifications sent to us about incidents affecting the service and people living there. We looked at the information we held on safeguarding referrals, concerns raised with us and applications the manager had made under Deprivation of Liberty Safeguards (DoLS).

Updated 10 August 2015

This unannounced inspection took place on 18 June 2015. We last inspected Bevan House in August 2013. At that inspection we found the service was meeting all the regulations that we assessed.

Bevan House provides accommodation and personal care for up to 40 older people, some of whom may be living with dementia. On the day of the inspection there were 22 people living in the home and two of the five units were unoccupied and closed. The service was only taking in new respite admissions. This was because Bevan House is one of the registered provider’s care homes that is due to close in the future as part of a programme to develop a new build care home locally.

The home is in a residential area of Barrow in Furness and close to bus routes into town. The home is on two floors divided into five living areas or 'units'. On the ground floor is accommodation on two units for people living with dementia. Each of the five units in the home has its own separate lounge and dining areas with a small kitchenette, toilet and bathroom facilities for those living there. There is a small car park to the rear and some outside patio space for people to use. The home has its own kitchen where food is prepared each day. There is a room for the use of people who wish to smoke and also a large communal lounge for people to use and for entertainments.

The service did not have a registered manager in post at the time of this inspection. 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 moved to another post within the organisation. The registered provider has recruited a suitable person who was in post and in the process of registering as the manager with CQC.

We spoke with people living at Bevan House in their own rooms and with those who were sitting in the communal areas. People told us that they were being looked after “very well” and that staff “did their best” to take care of them as they wanted. Relatives we spoke with told us that they did not have any concerns about how their relatives/friends were looked after and supported by the staff in the home.

We discussed the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) with the staff in the home. They had an understanding of the principles involved and what actions needed to be taken for people. We found that the information on file for decisions made around resuscitation and powers of attorney was not consistent. There were no clear records of who the people or representatives involved were or of the discussion or best interests meeting having taken place where there was a possible lack of capacity. We found a breach of Regulation 9 of the Health and Social Care Act (Regulated Activities) Regulations 2014. This was because formal policies and procedures were not in place in line with the MCA and associated code of practice. Staff had not consistently assessed people’s capacity and their ability to be involved in decision making and give consent in line with legislation.

You can see what action we told the provider to take at the back of the full version of the report.

We spent time with people on the three units. We saw that the staff offered people assistance but respected their independence. We saw that staff took the time to speak with people and took up opportunities to interact with them, engage and offer reassurance if needed.

The care plans and records that we looked at showed that people were being seen by appropriate professionals to help meet their particular physical, nursing and mental health needs. We saw that the assessment and management of risk had been reviewed and updated by staff so that people received appropriate support and treatment.

The environment of the home was welcoming and the communal areas were decorated and arranged to make them homely and relaxing and we found that all areas were clean and free from lingering unpleasant odours. We noted some minor maintenance issues needed attention with damaged plaster and paintwork and worn fixtures. These items detracted from the environment but did not present a safety risk to people living there.

We found that there were safe recruitment procedures and practices in place to help ensure staff who were employed were suitable for their roles. All the staff we spoke with knew the appropriate action to take if they believed someone was at risk of abuse. This had been part of the training staff received to be able to carry out their roles. We saw that care staff had received induction training and on going training and development and had supervision once employed.

We found that there were adequate staff on duty during the day. However there was not a formal dependency tool being used to help assess how many staff were needed to meet any changes in people’s personal care needs and on night shift.

Medicines were being safely, administered and stored and we saw that accurate records were kept of medicines received and disposed of so all of them could be accounted for. Controlled medicines [those liable to misuse] were in good order.

People knew how they could complain about the service they received and information on this was displayed in the home. People we spoke with were confident that action would be taken in response to any concerns they raised.