During an assessment under our new approach
Date of Assessment 26 June to 3 July 2025. This service is a residential care home providing accommodation and personal care for up to 38 older people, including people living with dementia and physical frailty. At the time of our inspection, there were 24 people using the service.The provider’s governance systems continued to fail to adequately assess and monitor the service effectively to drive improvements to the safety and quality of the service. Although the registered manager had recently developed systems to carry out regular checks, these had not been implemented fully into daily practice and did not identify on-going issues. People continued to be at risk of falls as their sensor mats were not always working or checked for their reliability.
The provider did not ensure all safeguarding issues were recorded or reported. Although staff had completed safeguarding training, some lacked confidence to escalate concerns. The provider was developing a system to use information from safeguarding incidents, accidents and complaints to improve people’s care.The provider did not have reliable systems to assess people’s risks or develop robust care plans to mitigate these risks. Staff did not always have the information they needed to mitigate the risks of falls, poor skin integrity, hydration, and nutrition. People’s care records did not always reflect their current needs, and documentation was not always completed or updated consistently.
There were enough staff employed to provider people’s care, however, the staff were not deployed or supervised adequately. People did not always receive their care in a timely way, as call bells were not answered, leaving people waiting for long periods for personal care.
People did not always receive their planned care. People were at risk of acquiring pressure ulcers as staff did not always assist people to reposition regularly to relieve their pressure areas.People were at risk of not receiving their medicines as prescribed. There was no reliable system to ensure all areas of medicines management were being followed in accordance with the provider’s policies.
The provider did not ensure there was consistent support for people living with dementia and with communication difficulties.People received their food and drink in a safe way, however, at times, people received their meals too close together as breakfast was served late.
The provider had taken action to address the concerns set out in the previous Warning Notice, and some improvements had been achieved. However, this inspection identified new areas where further improvement was still needed to ensure the service meets the required standards. While progress had been made, the service remains in breach of some legal regulations relating to safe care and treatment, safeguarding, consent, dignity and respect, staffing, and governance.
The service will continue to be closely monitored to support continued improvement. As some concerns remain and improvements are not yet fully embedded, Bethany Homestead remains in special measures. This approach is intended to help services make significant progress within a defined timeframe. Since the inspection people living in the service were supported by the provider and local authority to move to other care services. The provider has applied to cancel the registration for Bethany Homestead.