Updated 6 May 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by one Inspector
Service and service type
Bethesda is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Bethesda is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service.
We used all this information to plan our inspection.
During the inspection
We spoke with four people who used the service, eight staff, including the registered manager. We also spoke to three family members of people receiving support.
We reviewed five care records, three medicines administration records (MAR) and three staff records. We also reviewed other records, including policies and procedures, relating to the safety and quality of the service.
After the inspection
We continued to seek clarification from the provider after the inspection visit to validate evidence found. We looked at training data, rotas and quality assurance records.