This inspection took place on 25 and 26 May 2017 and was unannounced. The previous inspection was carried out in February 2016 and concerns relating to the management of some areas of medicines, some records relating to monitoring and checks, person centred detail recorded within people’s care plans and supervision opportunities for staff were identified. We asked the provider to send us an action plan about the changes they would make to improve the service. At this inspection we found that actions had been taken to implement these improvements.

Bethany House Care Home provides accommodation with personal and nursing care for up to 15 adults who need care and support with physical disabilities and complex needs, such as congenital disorders, degenerative illnesses and acquired brain injuries. At the time of the inspection there were 15 people living at the service, most were younger adults although the service also supported people who were older.

People were living with a range of care and nursing needs, many people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff. People's bedrooms were all en-suite and provided over two floors, with a passenger lift in-between. There was a large sitting and dining room on the ground floor and a quiet lounge on the first floor. On the ground floor there was also a hydrotherapy pool. Outside there was an enclosed garden and grounds which people could access.

The service had a registered manager who was available on the days 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.

Staff followed correct and appropriate procedures in the storage and dispensing of medicines. People were supported in a safe environment and risks identified for people were managed in a way that enabled people to live as independent a life as possible. People were supported to maintain good health and attended appointments and check-ups. Health needs were kept under review and appropriate referrals were made when required.

A robust system to recruit new staff was in place. This was to make sure that the staff employed to support people were fit and appropriate to be working with people. There were sufficient numbers of staff on duty to make sure people were safe and received the care and support that they needed. Staff had completed induction training when they first started to work at the service. Staff were supported during their induction, monitored and assessed to check that they had attained the right skills and knowledge to be able to care for, support and meet people's needs. Staff continued to receive training, competence checks and support to meet the needs of people. There were staff meetings, so staff could discuss any issues and share new ideas with their colleagues, to improve people's care and lives.

People were protected from the risk of abuse. Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns. Staff knew about whistle blowing and were confident they could raise any concerns with the provider or outside agencies if needed.

Equipment and the premises received regular checks and servicing in order to ensure it was safe. The registered manager monitored incidents and accidents to make sure the care provided was safe. Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do.

The care and support needs of each person were different, and each person's care plan was individual to them. Care plans, risk assessments and guidance were in place to help staff to support people in an individu

Bethany House Care Home is a purpose built service. It provides accommodation, nursing and personal care for up to 15 people who need care and support with their multiple and complex needs; the service was full at the time of inspection. People had a variety of physical disabilities including: acquired brain injury, congenital disorder and degenerative illnesses. The age range of people varied from young adults to people who were older. There are trained registered nurses working at the service 24 hours a day with a team of care workers.

There was a registered manager working at Bethany House. 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.

We last inspected this service on 15 October 2014. At that inspection we found some improvements were needed in respect of the understanding and implementation of the Mental Capacity Act 2005 by the provider, registered manager and staff and obtaining of consent. Accurate records of peoples care and support were not being maintained and some important health information had been overlooked. We asked the provider to send us a report of how they would address these issues and within what timescale, which they had done. At this inspection we found the provider had addressed most of the outstanding requirements but further shortfalls had been highlighted in regard to some operational and service user records.

People could be placed at risk because the provider could not assure their self through the records they maintained that all staff had received the recommended number of fire drills or that visual checks of fire equipment and some equipment used to support peoples care were taking place.

Staff said that they felt supported and the registered manager monitored their practice when she worked on shift with them but formal recorded staff supervision was irregular, with none recorded since August 2015; this meant there was no mechanism in place for recording staff performance and development throughout the year to inform their annual work appraisal or to monitor actions that have been highlighted for improvement.

Management of medicines required improvements. Staff showed that they had a good understanding of people’s individual styles and range of communication, but this information was not recorded to inform newer staff. Similarly, some people expressed their emotions from time to time through behaviour, staff understood this and how to de-escalate situations in the least restrictive way, their practice however, was not recorded in care and support plan guidance for all staff to ensure they responded in a consistent manner.

A service development plan was in place and relatives were asked to share their views about the service; there was however, no system in place to analyse their comments, and use these to inform the service development plan, nor a mechanism to provide feedback so people surveyed knew their views were listened to. Audits to assess and monitor service quality were largely undeveloped so the provider and registered manager could not assure their selves that all aspects of service delivery were operating to a good standard and any shortfalls were highlighted and dealt with.

People were given individual support with their interests and hobbies but we have recommended this be reviewed to ensure the range quality and frequency of activities is discussed with people and their relatives.

Relatives and staff referred to this as a ‘happy home’ and we saw that people were content, relaxed and comfortable in the presence of staff. Staff interacted well and showed they understood people’s individual needs.

Relatives told us they were kept informed and had been consulted about their family member

Bethany House Care Home is a purpose built service. It provides accommodation, nursing and personal care for up to 15 people who need care and support with their multiple and complex needs. People had a variety of physical disabilities including: acquired brain injury, congenital disorder and degenerative illnesses. The age range of people varied from young adults to people who were older. There are trained registered nurses working at the service 24 hours a day with a team of care workers.

There was a registered manager working at Bethany House. 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.

Each person had a care plan which was personal to them and that they or their representative had been involved in writing. Some of the care plans did not record all the information needed to make sure staff had guidance and information to care and support people in the safest way. Potential risks to people were identified but full guidance on how to safely manage the risks was not always available. This left people at risk of not receiving intervention they needed to keep them as safe as possible.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager and staff showed that they had considered their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). However, staff were not always following the Mental Capacity Act 2005 for people who lacked capacity to make a decision. The provider had not completed mental capacity assessments to identify if people were able to make decisions for themselves or if they needed specialist support to do this. The management had not gained consent from people who may have been restricted. The registered manager and the provider have now sought advice and direction to rectify this shortfall.

Throughout the inspection we observed people and the staff as they engaged in activities and relaxed. Some people communicated using non-verbal methods. Staff were able to understand people through body language, facial expressions and certain sounds and supported people in a discreet, friendly and reassuring manner. Staff asked people if they were happy to do something before they took any action. They explained to people what they were going to do and waited for them to respond. Staff were aware of people’s preferences and encouraged them to make choices when possible. They told us how they encouraged and enabled people to be as independent as they could be. People were treated with kindness and respect. Everyone told us their privacy was respected and they were able to make choices about their day to day lives.

People had allocated keyworkers who were involved in their assessments and reviews. A key worker was a member of staff who takes a key role in co-ordinating a person’s care and support and promotes continuity. People knew who their key worker was and what specific things their key worker did for them. People said that their keyworkers helped them plan and do things that they wanted to. One person said, “I have a key worker as she does the extra bits, like helping me buy my Christmas presents. But if she is not in I can ask anyone else for help”. People had regular involvement with local community health and social care specialists. They told us they saw their doctors and other specialists when they needed to.

Safeguarding procedures were in place to keep people safe from harm. All of the people told us they felt safe in the home; and if they had any concerns, they were confident these would be addressed quickly by their keyworker or by the registered manager.

Staff were appropriately trained and skilled and provided care in a safe environment. A system of recruitment was in place to ensure that the staff employed to support people were fit to do so. Staff received appropriate safety checks prior to working with people to ensure they were suitable. New staff received an induction and had access to range of training events. They received regular supervisions and support where they could discuss their training and development needs. There were sufficient numbers of staff on duty throughout the day and night to make sure people were safe and received the care and support that they needed. People said there was enough staff to take them out locally to the shops and for walks. They said that staff came quickly when they called for them and there was always staff around.

People were offered and received a balanced and healthy diet. Some people had a special way of receiving all the nutrients and fluids that they needed. People could choose what they wanted to eat and when they wanted to eat it. People’s rooms were personalised and furnished with their own things. The rooms reflected people’s personalities and individual tastes.

People received their medicines safely and when they needed them and they were monitored for any side effects.

The provider asked people for their opinions on the quality of care they received and responded to comments and complaints in a timely and appropriate manner. People’s opinions and preferences were respected. People could choose if they wanted a male or female member of staff to help and support them. There were appropriate management arrangements in place and staff and people told us they had no problems talking to managers about any concerns. People were actively involved in developing the service through regular meetings with staff and the provider. Regular health and safety audits were carried out to ensure the safety of the premises.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We found that people were positive about their experience of using this service. One person said that the staff were “So kind to me” and that “I haven’t got anything but a kind word” for the staff. We spoke with one relative who described the staff as “friendly” and said that they “listen to you”. Several people commented on the low staff turnover at the service as a positive point. This meant staff knew people using the service well and could provide consistent care.

Most of the people who use this service were not able to comment directly on their care due to communication difficulties. However, we observed the way staff interacted with them and noted that they were aware of how people could make their feelings and wishes known through facial expressions and vocalisations. Staff could interpret signs that a person may be in pain for example in order to provide pain relief and seek medical attention if required.

We looked at the systems in place to ensure effective infection control and spoke with staff including domestic staff. We found that staff had a good understanding of infection control procedures and were given appropriate training as part of their induction.

We found that the people were aware of the complaints procedure. They were confident that they could raise concerns and they would be dealt with appropriately. Staff showed a good awareness of how to support people if they wanted to make a complaint.

The service was fully occupied at the time of the inspection. Most people were unable to talk to us directly about their experiences due to their complex needs, so we used a number of different methods to help us understand their experiences. We spoke with staff on duty, read records, spoke with a relative and observed some of the support given to people.

Records showed that people were supported to make decisions about their day to day lives and things that were important to them. People could choose when to get up and go to bed, what to do and what to eat each day and staff respected their choices.

Staff understood people’s needs and their individual methods of communication. People’s health care needs were met and they were supported to keep in contact with health care professionals. A person said they liked the staff and that staff were kind and polite. They said “they are so friendly and kind” and “they are marvellous”.

The service was clean and well maintained and people told us that they liked their rooms. Bedrooms reflected people's personalities and shared areas were spacious with plenty of room for people who used wheelchairs to move around in.

There were enough staff on duty to support people safely. The organisation had processes and procedures in place to regularly check on the quality of the service people received and to keep them safe.