About the service: Bethel / Bethesda is a residential care home comprising of two connected buildings that was providing personal and nursing care to 28 people aged 65 and over at the time of the inspection.

People’s experience of using this service:

• The provider had made improvements to ensure that people lived in a safe and secure environment. They had acted on all the recommendations made by the local fire and rescue service following an inspection they had carried out.

• The provider and registered manager had made improvements to systems that kept people safe from avoidable harm and to how the service was run. However, it was too early to say whether all the improvements were embedded.

• People had personal emergency evacuation plans that staff were familiar with which meant they would be safely evacuated in the event of an emergency such as a fire.

• Staff did not always lock doors to the laundry or a room with cleaning equipment when these rooms were unattended.

• A door to a passageway connecting the two buildings was left unlocked. This area was unmanned. Relatives told us they accessed the home this entrance instead of via reception where they signed a visitor’s book. They were concerned that unauthorised visitors could do the same.

• The provider increased their checks to ensure the doors to those areas were locked.

• The provider had improved the arrangements for the maintenance of the premises and equipment such as heating and hot water systems. People told us they were warm in their rooms and communal areas.

• People were provided with enough healthy and nutritious food. The provider had arrangements for ensuring that there was always enough food and drink in store.

• People told us they felt safe living at the home and when staff supported them.

• People had their medicines at the right times because the provider and registered manager had improved arrangements for managing medicines safely.

• The provider employed enough staff so that they could meet people’s needs in a timely way. Staff responded quickly when people used their call alarms.

• The provider and the registered manager were clear about improvements they wanted to make. They were working on a plan to include people, relatives and staff in improving the service.

• The provider had arrangements for monitoring the quality and safety of the service.

• At this inspection, whilst we saw improvements had been made, it was too early to say whether the improvements were embedded. However, the provider was no longer in breach of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations.

Rating at last inspection: At our last inspection on 15 August 2018 (report published 31 October 2018) we rated the service as Inadequate. We placed the service in special measures.

Why we inspected: After our last inspection we issued a warning notice because the provider had failed to make improvements to how they assessed, monitored and sought to improve the quality, health, safety and welfare of service users. This was a continuing breach of the Health and Social Care Act 2008 (Regulated Activities) 2014 Regulations, regulation 17 (2a and b) - Governance. We placed the service into special measures.

We inspected the service against two of the five key questions we ask about services; is the service Safe and is the service Well-led? Those the key questions were rated as inadequate at our last inspection. We followed-up on the actions the provider had taken in relation to the warning notice.

Follow up: We will continue to monitor the service and we will carry out a comprehensive inspection of all five key questions as per our re-inspection programme. We will decide then whether to remove the service from special measures.

This inspection took place on 15 August 2018 and was unannounced.

This was the fourth comprehensive inspection carried out at Bethel/Bethesda Residential Home. At the last inspection in August 2017 the service was rated as requires improvement. At this inspection we found there were areas that still required improvement.

Bethel/Bethesda Residential Home is a care home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates up to 34 people in one adapted building. On the day of our visit, there were 25 people using the service.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission 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 provider had not ensured there were sufficient processes in place to assess, monitor and improve the quality of the service to maintain the health, safety and welfare of service users. The provider had not ensured that people were always protected from health and safety risks associated with accessing areas such as the kitchen and laundry; or ensured there were adequate systems in place to make repairs to the home or the hot water system.

People could not be assured there were enough staff to meet their needs. Staff did not receive all the support they required to carry out their roles.

People could not be confident their complaints would be responded to appropriately.

The provider did not ensure that people could access all areas of the home as two communal areas were used for storage.

People were encouraged to make decisions about how their care was provided and their privacy and dignity were protected and promoted. People had developed positive relationships with staff. Staff had a good understanding of people's needs and preferences.

People received care from staff that had received training to meet their needs. Safe recruitment processes were in place.

Staff understood their roles and responsibilities to safeguard people from the risk of harm. Risk assessments were in place and were reviewed regularly; people received their care as planned to mitigate their assessed risks.

People were supported to have enough to eat and drink to maintain their health and well-being.

People were supported to be involved in their care planning and reviews. Their care and support was delivered in the way that people chose and preferred.

People were supported to access relevant health and social care professionals. There were systems in place to manage medicines in a safe way.

Staff demonstrated their understanding of the Mental Capacity Act, 2005 (MCA). Staff gained people's consent before providing personal care. People were involved in the planning of their care which was person centred and updated regularly.

At this inspection we found that Bethel/Bethesda Residential Home were in breach of four regulations relating to staffing, safe care and treatment, receiving and acting on complaints and governance of the home.

This is the third consecutive time the service has been rated Requires Improvement. The actions we have taken are reported at the end of the full report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improve

The inspection visits took place on 4 and 5 July 2017. The first visit was unannounced and the second was announced.

Bethel/Bethesda Residential Home provides care and support for up to 34 older people. At the time of our inspection 19 people were using the service.

There was a registered manager in place. It is a requirement that the service has a registered manager. 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 2008 and associated Regulations about how the service is run.

At our previous comprehensive inspection carried out on 26 August 2016 and 1 September 2016 we asked the provider to make improvements. We asked them to improve their practices in relation to safeguarding people from abuse and assessing risks. We also asked them to improve their practices in relation to their arrangements for monitoring the quality of the service and notifying CQC of significant events at the service. We asked them to display their most recent rating given by us as this was not in place and is a requirement. Following that inspection the provider sent us an action plan detailing what improvements they were going to make. During this inspection we found that some improvements had been made.

People felt safe living at Bethel/Bethesda Residential Home. Staff knew their responsibilities to help people to remain safe. They took action where they had concerns that a person was at risk from abuse or harm. Risks to people’s health and well-being were mainly assessed and reviewed to provide guidance for staff. The registered manager told us they would make improvements to the care records where this was required. Staff took the appropriate action when an accident or incident occurred. The registered manager analysed any accidents or incidents to prevent a reoccurrence where possible.

The provider had not always checked the environment and the equipment people used to help people to remain safe. They were planning to implement further checks to maintain the security of the home.

Staffing numbers were suitable to offer people the care and support they required although we received mixed feedback about this. The organisation of staffing required improvements and the provider told us that they would undertake this. The provider carried out checks on the suitability of new staff to make sure that people were supported by those who had been verified as safe.

People received their medicines by staff who knew their responsibilities for handling them safely.

People received support from staff members who received training and on-going guidance on their work. New staff did not receive a formal induction when they started work. Staff generally felt supported by the registered manager.

Where there were concerns about people’s ability to make decisions for themselves, the registered manager had undertaken assessments to determine people’s level of understanding. Decisions made in a person’s best interest occurred in line with the Mental Capacity Act 2005. Staff understood their responsibilities under the Act.

People were not always satisfied with the food available to them. The provider had employed a new cook who had spent time asking people about their preferences.

People had access to a range of health care services to help them to remain healthy. Staff took action where there were concerns about a person’s health or well-being.

People were cared for by staff who were generally kind. People’s privacy and dignity was respected by staff. People were involved in decisions about their care. Information about advocacy services was not available to them. Staff knew the people they supported and encouraged them to retain their skills.

People received care and support that was mainly centred on things that mattered to them.

We inspected the service on 16 January 2017 and the visit was unannounced. This meant the provider and staff did not know that we would be visiting.

We carried out an unannounced comprehensive inspection of this service on 26 August 2016 and 1 September 2016. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements. We issued a warning notice in relation to the breach of Regulation 11; need for consent of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met the legal requirement. This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Bethel/Bethesda Residential Home on our website at www.cqc.org.uk.

At the last inspection we carried out on 26 August 2016 and 1 September 2016 we found that where people lacked the capacity to consent to their care and treatment, the provider had failed to act in accordance with the provisions of the Mental Capacity Act 2005 (MCA). We also found that staff did not understand their requirements under the Act. At this inspection we found the provider had made some of the required improvements.

Bethel/Bethesda Residential Home provides care and support for up to 34 older people. At the time of our inspection 18 people were using the service and some were living with dementia or similar conditions.

There was a registered manager in place. It is a requirement that the service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission 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 2008 and associated Regulations about how the service is run.

People were not always supported in line with the Mental Capacity Act 2005 (MCA). People were not always asked for their consent before staff carried out care and support. Where there were concerns about people’s ability to make decisions, the provider had not completed assessments in line with the MCA. Decisions made in people’s best interest were not recorded to show how these had been agreed. Staff understood their responsibilities under the Act. The provider had made applications to the appropriate body where they had sought to deprive a person of their liberties.

Staff received training and guidance relevant to their role. The guidance they received was not always effective. For example, staff did not always communicate with people when offering their support.

People had mixed views on the food available to them. The registered manager was taking action to make sure improvements were made. Where there were concerns about people’s eating and drinking, people’s care records were not always full completed to provide guidance to staff. The registered manager told us they would review people’s records where the information was not complete to make improvements. Staff knew what actions to take should they have concerns about people’s eating and drinking.

People had access to health care services such as their doctor and district nurse visits.

We inspected the service on 26 August 2016 and 1 September 2016. The first day was unannounced and the second was announced.

Bethel/Bethesda Residential Home provides care and support for up to 34 older people. At the time of our inspection 22 people were using the service. The accommodation was offered over one floor. There was a communal lounge and two dining areas. There was also a courtyard for people to use should they wish to.

At the time of our inspection there was a registered manager in place who had recently returned to work after an extended period of leave. It is a requirement that the service has a registered manager. 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 2008 and associated Regulations about how the service is run.

People were not always supported in line with the Mental Capacity Act 2005 (MCA). People consented to their support where they could. However, the provider had not assessed people’s mental capacity where this was necessary and best interest decisions were not in place. Some people did not have the capacity to make certain decisions. It was not clear how some decisions had been made and whether people should make the decision for themselves. We saw some people may have restrictions placed upon them as they were not able to go out alone and may not have had the capacity to make a decision about their safety. Applications to ensure these restrictions were lawful had not been made for all these people. Staff did not fully understand their responsibilities under the Act.

Staff understood their responsibilities to protect people from abuse and avoidable harm and to remain safe. However, the provider’s policy to safeguard people was not followed on one occasion in relation to an allegation of abuse. The provider had a system for recording accidents and incidents but it did not include a robust analysis to reduce their reoccurrence where possible. Although people mainly felt safe, risks to people’s health and well-being were not always regularly assessed. For example, where people were at risk of falling, staff did not always have information available to them.

The provider had not always checked the environment for risks that people could have been exposed to. Fire safety checks had not always occurred and where there were actions identified by trained professionals to protect people’s safety these were not always completed. Staff did not have an emergency plan available to them to provide support to people in the event of, for example, a fire.

The provider had a suitable recruitment process in place for prospective staff which included relevant checks. However, people and staff had mixed views on whether the provider had enough staff to offer safe care. We found that on occasion people had to wait to receive care.

People received their prescribed medicines in a safe way. Staff followed national guidance when offering people their medicines and received training to understand their responsibilities. Medicines were stored appropriately. However, the provider’s checks on people’s medicines were not completed correctly which meant that mistakes that may have occurred would not have been picked up in a timely way.

People did not always receive care and support from staff with the appropriate knowledge and skills. Staff had received regular training in topic areas such as fire safety but not in specific conditions that people were living with including dementia. New staff did not always receive an induction when they started to work for the provider. They did not have regular meetings with a manager so that they could receive feedback and guidance on their work.

The provider had not always sought the support of specialists where there were concerns about people’s nu

We inspected the service on 12 November 2014. The inspection was unannounced.

Our previous inspection was on 4 March 2014 when we found that the service was meeting the essential standards we inspected.

Bethel / Bethesda is a residential care home that provides accommodation for up to 34 elderly people who require personal or nursing care, but nursing care is not provided. At the time of our inspection 24 people used the service.

It is a condition of registration for the service that it is managed by a person who is a registered manager. A registered manager is a person who has registered with the Care Quality Commission 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. At the time of our inspection the registered manager had been absent for more than 28 days. The absence began in June 2014.

The provider’s arrangements for the management of the service pending the registered manager’s return were effective, but aspects of the arrangements for monitoring and assessing the service required improvement.

People we talked with spoke positively about the service. People who used the service and relatives told us it was a safe home. Staff we spoke with knew how to keep people safe. Staff knew how to identify signs of abuse and how to report it. They were confident that any concerns they raised with the acting managers or the owner would be taken seriously and investigated. Staff also knew how they could raise concerns about people’s safety and welfare with the local authority, the police and the Care Quality Commission.

People’s plans of care included risk assessments of activities associated with their support routines and risks associated with their limited mobility. The use of mobility equipment had been risk assessed to ensure that staff used the equipment safely. Other risk assessments included guidance about how to support people with personal care.

Staffing levels were based on people’s dependency levels. This meant that more staff could be on duty if people’s needs increased. The provider had effective recruitment procedures. The recruitment procedures had ensured as far as possible that only people suited to work at the service were recruited.

People received their medicines when they needed them. The service had arrangements for the safe management of medicines.

People’s plans of care were individualised and contained information about people’s assessed needs and how those needs should be met. The plans included people’s life histories and details of their likes and dislikes. Staff we spoke with had a good knowledge of people’s needs. Staff acquired their knowledge from talking with people. People told us their needs were met and that staff were attentive and quick to respond to calls for assistance.

People who used the service felt that staff understood their needs. The training staff received helped them provide care and support to the people who used the service.

Staff were aware of the relevance of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This is legislation that protects people who are not able to consent to care and support, and protects them from unlawful restrictions of their freedom and liberty. No person was under a DoLS authorisation.

People’s nutritional needs were met. People liked the food the service provided and that they had a good choice of food. Staff ensured that people had enough to drink throughout the day and people had drinks available in their rooms at night.

People had access to healthcare services. Delivery of care reflected the advice and guidance provided by healthcare professionals, for example doctors and nurses.

Staff supported people with kindness and care. People expressed their views about their care and support when they spoke with staff and at `residents meetings’. Relatives had also attended those meetings. People’s privacy and dignity were respected. People’s rooms were personalised with family photographs and belongings. That had contributed to people’s sense of comfort and independence.

People told us they knew how to raise concerns and that they were confident they’d be listened to.

As this visit was a follow up on outstanding compliance action linked to infection control and the environment we did not talk to people using the service on this occasion. We did briefly talk to two staff who told us how much better the home looked and what a happy environment it was to work in. We saw that a great deal of improvement had been made in the environment and the hygiene practices within the home. The provider has taken the necessary action to make the improvements required.

We looked at two outcome during this visit as we had issued a warning notice and a compliance action. We noted improvements had been made and as such we will not be taking further enforcement action, however we will continue to monitor the service to ensure compliance is reached.

We spoke with people about the hygiene of the service and they told us that they were happy with their rooms as they were cleaned regularly. We saw improvements had been made in creating systems to ensure the home was clean and cross infection was minimised.

People using the service and staff told us that they were pleased with the improvements. We saw that building work had started and some improvement had been made to the fabric of the building such as a new shower room and communal areas were decorated. As the work is not yet finished we will continue to monitor the service.

This inspection was to follow up from the last inspection to ensure things had improved.

People using the service and staff told us that they thought things had improved in the last few months but there was still areas that could be improved such as the environment. People told us that on the whole they liked living at the home but that the activities at the home were limited.

We looked at five care plans and saw that four of the five had been improved and were fit for purpose.

We looked at training records and although not yet completed we saw that staff were being booked on future training course to ensure that they had the skills and abilities to meet people's needs.

We toured the premises and found that it was badly maintained and in need of serious refurbishment.

We spoke with nine people using the service and their relatives, they told us that although they were mostly happy with the care they were concerned about the lack of activities and that staff seemed very busy. Staff confirmed that they lacked time to do anything other than basic care.

We found that care plans lacked detail and people using the service were at risk of not receiving their assessed and planned care. Records showed some people had lost sufficient weight to indicate there may be underlying health concerns but this had not been followed up with a referral to an appropriate specialist.

We saw that despite their being dignity champions at the home people were not always treated with dignity and respect such as staff speaking too loudly and people left in an unkempt state of dress.

Although there were infection control systems in place, due to the lack of maintenance there was risk of cross contamination in key communal areas such as toilets and bathrooms.

People were placed at risk because arrangements for recording, storage and administration were poor. People using the service told us that even staff who had not worked at the home for very long soon administered medication raising their concerns about standards.

We looked at staff rotas and training records. Rotas were confusing and did not always ensure that were sufficient well trained staff on duty. Staff also told us they did not feel supported or receive quality training.

We spoke with five people who use the service and two relatives they told us that overall the care they received was good but they were often bored.

"Staff are very caring."

"I attend the craft club and I feel occupied."

"The home puts on quizzes and bingo but there hasn’t been much entertainment since Christmas."

The relatives we spoke with told us "mum feels so secure here, nothing is too much trouble. Communication is good, staff always let us know of any changes."

"They give us alternatives if we don't like the main meal but it isn't a proper meal, it's an omelet or baked potato."

"Tea is always the same soup and sandwiches, no alternatives are offered,you get bored."

"I am quite happy with the choices and the meals."

"If you ask they will do it to the best of their ability".

"The food is not usually good someday's are better than others".

"They pulled out all the stops when my relative became ill".

"Some care staff are good and help, sometimes you can pull the cord and no one comes".

"All the staff are kind to me".

"Residents meetings mostly about trips and activities, we aren't listened to really".

We chose not to speak to people using the service during this visit as we were following up identified concerns from the last inspection that related to managerial practices. For comments made by people using the service at previous inspections please look at earlier reports.