This unannounced inspection took place on 06 and 12 June 2018. At the last inspection on 17 and 18 October 2017, breaches of legal requirements were found and we gave the service a rating of 'inadequate' under the questions ‘is the service safe and effective’. This meant the overall rating was ‘inadequate’ and the service was placed into special measures. This was because people were not always safeguarded from the risk of harm because possible safeguarding issues had not been reported to the appropriate authorities. Risks relating to people had been assessed but the service was not always effectively delivered to reduce the risk of avoidable harm to people. People were being unlawfully restricted because the legal processes had not been followed. Risks relating to people's healthcare needs and weight had not been effectively assessed and action taken to manage the risk had not always been identified or planned. Referrals to professionals were not always made when it became necessary. The service was rated as requires improvement under the questions ‘is the service caring, responsive and well-led’. This meant people were not consistently receiving a service that was safe and did not consistently meet their needs or comply with the requirements of the law. After our inspection in October 2017, the provider met with us and it was agreed they would provide us with monthly updates outlining how they were improving the service and meeting the legal requirements in relation to the breaches.

During this most recent inspection, we found the provider had made the necessary improvements to meet the breaches of Regulations 11, 13(1), 15, 17 and Registration Regulation 18 identified at the last inspection.

Where people lacked the mental capacity to make informed decisions about their care, we found there had been an improvement with the completion of mental capacity assessments. However, improvement was still required around the provider’s and staff understanding of what could constitute a restriction on a person and when to submit an application to lawfully restrict a person, in their best interest.

Potential risks to people had been identified. Although skin management processes required improvement and staffs’ practice when moving and transferring people did not always follow guidance to minimise the risk of avoidable harm.

Full information about CQC's regulatory response to issues and concerns found during inspections are added to this report after any representations and appeals have been concluded.

Bethany House 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. At the time of our inspection 20 people were living at the home.

The registered manager is also the provider. 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.

Systems used for the effective management of information about people's changing needs and risks required further improvement to ensure people's safety was maintained. The provider was notifying the local authority and CQC about incidents and events as required by law. Staff knew how to escalate any concerns for people's safety and well-being but there was further training required to improve their knowledge on what constituted a restriction on people and moving and transferring people. The home environment was clean and improvements were underway to introduce a more dementia friendly environment, with systems in place to monitor the improvements and audit infection control practices.

People’s health care needs

This inspection took place on 17 and 18 October 2017 and was unannounced on the first day and announced on the second day. At the last inspection on 21 and 22 April 2016, we found that the provider was ‘good’ under the key questions of safe, effective, caring and responsive and required improvement under the well-led.

Bethany House is registered to provide accommodation and residential care for up to 30 people, most of whom were living with dementia. At the time of our inspection 28 people were living at the home.

It is a legal requirement that the home has a registered manager in post. The registered manager is also the provider. 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.

At our last inspection in April 2016, improvements were required to the management of the service. At this recent inspection we found improvements had not been made and we identified further areas of concern.

Systems in place to monitor and improve the quality of the service were ineffective in ensuring people received a good and continually improving quality of service. The audits had not identified the issues we found and had not always been consistently applied to ensure where shortfalls had been identified, they were investigated thoroughly and appropriate action plans put into place to reduce risk of reoccurrences.

Where people lacked the mental capacity to make informed decisions about their care, it was not always clear how relatives, friends and relevant professionals were involved in best interest's decision making. Mental capacity assessments and best interest decisions were not always applied consistently to clearly show what decisions people were being supported or asked to make in relation to their care. Application to apply for a Dols for people who had mental capacity showed that the provider did not have effective systems to ensure staff understood the legislationso people’s rights were protected. Some applications had been submitted to deprive people of their liberty, in their best interests; we found applications were not always submitted in a timely manner.

People were supported by suitably, recruited staff that had received training to identify signs of abuse to keep people safe. However, staff had not always followed safeguarding procedures when there had been verbal and physical altercations between people living at the home. Potential risks to people had been identified although staff practice did not always follow guidance put in place to minimise the risk of avoidable harm. People were supported by sufficient numbers of staff to receive their care and support. People were supported with their medicines, however, there was an improvement required with the administration of medicines.

Most people spoke positively about the choice of food available, although there was some inconsistency with staff not always ensuring people were given a choice of food available. People who were on food supplements received them, however, a number had consistently lost weight and referrals made to professionals were more reactionary as opposed to preventative. People were supported to access health care professionals, however this was not always consistent and some improvement was required. People’s health care needs were assessed and reviewed but people were not always referred to professionals in a timely way when health needs changed. Relatives told us the management team were good at keeping them informed about their family member’s care.

People and relatives told us that staff were kind, caring and friendly and treated people with respect, although there were occasions when people’s privacy was not maintained. The atmospher

This inspection took place on the 21 and 22 April 2016. The first day of the inspection visit was unannounced, the second day was announced. At our last inspection on 17 and 18 February 2015, the service was found to be requiring improvement. This included recruitment checks, medicine management, risk assessments, restrictions on peoples’ liberty and ineffective systems to identify where improvements were required to the service. We found there had been some improvements made.

Bethany House is a home providing accommodation and residential care for up to 30 people. The home also provides short stay interim beds for people that require respite care. At the time of our inspection 26 people were living at the home.

There was a registered manager in post at the time of the inspection. 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.

At the last inspection it was found the provider had not always recognised when the care being offered had put restrictions on people’s ability to choose and move around freely. There had been an improvement. People had access to equipment to help them move freely around the home and measures had been put in place to ensure the provider was meeting the legal requirements to protect people’s human rights.

Systems were in place to monitor, audit and assess the quality and safety of the service but they had not always been effective at identifying the issues we found during this inspection and required improvement.

People felt safe living at Bethany House. Staff understood their responsibility to take action to protect people from the risk of harm because the provider had systems in place to minimise the risk of abuse.

There were sufficient numbers of staff available to support people. Suitable staff had been recruited and had received training to enable them to support people with their individual needs.

People felt supported to take their medicines.

People were able to choose what they ate and drank and enjoyed their meals and given the opportunity to join in different activities if they wished.

People were supported to receive care and treatment from a variety of healthcare professionals and received treatment if they were unwell.

Staff demonstrated a positive regard for the people they were supporting. People felt staff were caring and kind. Staff understood how to seek consent from people and how to involve people in their care and support.

People felt happy living at Bethany House. There was a complaints process in place and people felt they could raise concerns. Feedback on the service provided at Bethany House was sought from people living at the home, their relatives and professionals.

During our visit we spoke with two people living in the home, five relative, five staff, the manager and a visiting health care professional to ask their views about the service provided to people.

Some of the people who lived at the home had dementia care needs. People with dementia are not always able to tell us about their experiences so we looked at records relating to their care and observed staff caring for them.

The two people we spoke with told us staff were kind and helped them. All Staff spoken with were able to tell us about people's care needs so that they received care in a way that they preferred. All five relatives told us they were consulted about their relative's care and kept informed about their relative's health so they felt involved in their care. One relative told us, "I am informed about all aspects of my relative care and consulted about any health issues they may have''.

On the day of our visit we saw that people were supported to eat their food when needed, we saw that the meal time was rushed and not organised. This meant on the day of our visit people did not have their meal in a calm and relaxed way and this did not enhance their experience of the meal time.

Staff received a range of training so that they had up to date knowledge and skills in order to support the people who lived in the home.

The provider had systems in place to monitor the service provided, but these were not always used and monitored effectively.

We visited Bethany House on 25 January 2012. We did not tell the home we were visiting them. Some people living in the home were unable to tell us about the service they received. We spoke to three people and three relatives of people living in the home. We spoke to four health or social care professionals who visited the home.

People living in the home told us that care workers: "...Were kind and were patient." They told us that care workers didn't have much time to talk to them as they were busy cleaning.

Some people wanted to stay in bed later and wanted more activities.

Relatives told us that the care workers were caring. They said that they thought people in the home could have more to do. They said that they were contacted if their relative needed anything.

We spoke to health and social care professionals. They told us care workers did everything that was asked of them. They said that care workers needed to be more proactive in how they managed peoples care. Some told us that they thought that the environment needed to be updated.

The inspection took place on 17 and 18 February 2015 and was an unannounced inspection. We last inspected the service on 15 November 2013 At the last inspection the provider was meeting all regulations inspected.

Bethany house provides accommodation for up to 30 people. There were 28 people living there on the day of our visit. There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People felt safe with the staff that supported them, The care and support provided sometimes restricted people’s ability to get up and walk around when they wanted because they were at risk of falling. Safeguards were not in place that enabled people to take some risks that would improve their quality of life.

People told us they were supported to take their medicines as prescribed but there were occasions when medicines were not available and the records did not show why they were not available.

There were sufficient numbers of staff available to support people. Staff had received training in how to support people so they could support people with their care needs. However staff did not understand how people’s rights could be restricted inappropriately by the way they supported them.

Recruitment procedures did not ensure that all the required checks had been carried out to check staffs conduct in previous employments.

People were consulted about the care they received. People’s choices and preferences were known by staff so that people received care on an individualised basis.

People were supported to access health care services and timely referrals were made to health care professionals when needed to ensure people remained healthy.

People were supported to take part in organised group activities or individual activities of their choice in the home and also maintain links with the people who were important to them.

People were able to raise concerns and felt that they would be listened too and actions taken to address their concerns.

Systems were in place to monitor and check the quality of care provided but the monitoring checks were not always effective and did not identify the actions needed to improve the service.