Inspection on 14/09/07 for Bay House

This inspection was carried out on 14th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bay House 28/08/08

Bay House 03/10/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bay House 2-3 Middlesex Road Bexhill-on-Sea East Sussex TN40 1LP Lead Inspector Debbie Calveley Unannounced Inspection 14th September 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bay House Address 2-3 Middlesex Road Bexhill-on-Sea East Sussex TN40 1LP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01424 210202 01424 210202 info@amberbeach.co.uk Mr N Manji Claire Avery Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only Nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - (OP) The maximum number of service users to be accommodated is 36. Date of last inspection 3rd October 2006 Brief Description of the Service: Bay House is a converted Victorian property that was formerly a Guest House. It is situated in a quiet residential area of Bexhill close to the seafront, town centre and mainline railway station. Bay House Nursing Home is registered to provide general nursing care to older people. Bay House has recently been purchased as an on-going concern by Mr N Manji and was registered, by the CSCI, in his name on 7th August 2006. The home is registered to accommodate thirty-six residents. The home at present is undergoing a major refurbishment that will affect the amount of double and single bedrooms. Some bedrooms have en suite facilities, with additional toilet and bathroom facilities throughout the premises. There is a small lift shaft servicing all floors. The home has specialist equipment including specialist beds, bath and lifting hoists and walking aids. There is a well maintained garden to the rear of the property that is accessible to service users. Unrestricted parking is available on the road on which the home is situated. Potential new service users can obtain information relating to the home via the internet, CSCI Inspection Reports, Care Managers, Placing Authorities, by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) were £482 - £675 per week, with additional charges made for hairdressing, newspapers/magazines, transport and chiropody. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 5 Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Bay House will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 6.5 hours on the 14 September 2007. There were twenty-two residents living in the home on the day, of which five were case tracked and spoken with. During the tour of the premises ten other residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment files. Four members of care staff, house keeping manager, maintenance manager and the catering manager were spoken with in addition to discussion with the Manager and Registered Provider. Six resident/ relative surveys were received regarding the service provided at Bay House. The information received from the surveys, and from telephone contact with visiting professionals and the two relatives spoken to during the inspection has been incorporated into the report. An Annual Quality Assurance Assessment was received from the Manager completed in full prior to this key inspection. Some areas of the report will be focusing on the plans of the management team on completion of the major refurbishment of the home. What the service does well: There is a Statement of Purpose and Service Users Guide that gives prospective residents the information required to enable them to make an informed choice about where they live. Residents confirmed that they were visited by the Manager prior to admission to the home and two stated they had been invited to visit the home to see if they liked it enough to live there. Comment received ‘ we were invited to tour Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 7 the home, and to see the room, were most impressed with how the “face lift” was undertaken and not allowed to disrupt clients and care’. Contracts are clear and given to all residents. Comment received ‘ all questions answered clearly and concisely with reference to the contract’. The pre-admission assessments are completed to a good standard. The menus evidence a well thought out balanced diet with a varied choice of food in line with resident’s preferences. There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard residents’ finances. Staff provision is well maintained with a robust recruitment practice being followed and appropriate numbers of suitably qualified staff working in the home. ‘Everything that could be done, medically, emotionally and on a practical level is carried out with the up most professionalism, empathy and thoughtfulness’. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The Comments received from residents and families regarding the care received included: ‘ Staff are kind and helpful ’ ‘ the staff are kind and observant to patients needs’ ‘ within two days of his admission to the home I noted how much more alert, clean and comfortable he appeared’ ‘ She receives excellent nursing care and care workers are kind, considerate and supportive of her every need’ Despite the building work the staff work hard to provide a clean, safe and wellmaintained environment, which is appreciated by the residents and their relatives. Comment received ‘ ‘ public areas kept clean and my relatives room is cleaned daily’. Comments regarding Bay House were generally positive and included: ‘I have been here for a long time and like it’ ‘ I haven’t been here long, but its quiet and peaceful, I am comfortable’. What has improved since the last inspection? The medication practices in the home have improved considerably and are safe ensuring the residents health needs are protected. The home have updated the Statement of Purpose and Service User Guide to reflect the change of ownership and management of the home. It is available to all residents and relatives. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 8 A new format of care planning has been introduced and the pre-admission assessments are completed in full and ensure that the prospective residents needs can be met by the home. Staff recruitment files have been updated to include all recruitment checks, health checks, registered body checks and other documentation required by the regulations in order to ensure that only suitable staff are recruited by the home. The Manager was registered by the CSCI in February 2007. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives with a good level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission thus ensuring that the home has the necessary skills and facilities to meet their needs. EVIDENCE: The Statement of Purpose and Service Users Guide were found to be informative and written in a user - friendly format. These documents have been updated and now reflect the changes required at the last inspection. The manager will continue to update and review these documents as the refurbishing and extension are completed. It was confirmed by the Registered Provider that all residents receive a contract that is specific to Bay House and the new owner. A contract was viewed and found to be comprehensive Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 11 Since the last inspection a new care planning system has been introduced, the last three admissions to the home were identified and the records relating to the admission procedures followed were reviewed. This confirmed that pre admission assessments are completed and provide a clear assessment of prospective residents care needs. These are completed by the manager and discussion with the manager confirmed that these are used to ensure new admissions to the home are appropriate and that the home have the staff, equipment and environment to meet their care needs. Prospective residents’ are seen either in their home or hospital before admission and the input from relatives and other professionals is used whenever possible. This approach should be more clearly recorded on the assessment documentation to demonstrate the procedure followed. It was however noted that the home does not confirm having regard to the assessment that the home can meet the assessed needs of the prospective resident. This was discussed with the manager who was advised that this should be completed in writing in accordance with the required documentation. The manager was able to verbally demonstrate her knowledge and awareness of the different specialities required in the home and ensures that the Registered Nurses and carers employed have attended relevant courses to deal with the needs of the elderly and also specialised courses for certain diseases. Trial visits to the home can be arranged. The manager confirmed that residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. Intermediate or rehabilitative care is not provided at Bay House. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although care documentation provides a framework for the delivery of care it needs to be developed to provide clear guidance to care staff on all the care needs of the residents, along with robust systems for risk assessment to ensure individual person centred care is delivered. The home’s practice ensures residents’ medicines are stored and administered safely and residents are treated with respect and have their privacy and dignity maintained. EVIDENCE: A new care plan system has been implemented since the last inspection and this has required a great deal of work on the part of the senior staff in the home to input all the necessary information. The inspection process however identified a number of short falls in the care documentation albeit that it is Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 13 acknowledged that this system has only been operational for a short period of time. The care documentation pertaining to five residents was reviewed as part of the inspection process. These were found to include plans of care, nutritional assessments, personal histories and risk assessments. On the whole the care documentation demonstrated that the care was reviewed and evaluated, however it was noted that not all the plans of care highlighted all the needs of residents. For example one resident who has communication problems did not have any guidance in the documentation to facilitate this vital need. Another did not provide any guidance for staff in caring for catheters or in promoting continence. Resident’s mental health needs were not fully explored with an action plan to monitor boredom and depression. It was also found that social histories and social care plans are not completed on all residents. Care staff complete a tick box personal care sheet, which is kept in the residents room, not all were current and the manager was to review if this system works and who checks that they have been completed. The care plan system used has risk assessments included and these were not completed in full. Systems for risk assessing resident’s nutritional status are in place although these need to be followed up thoroughly within the care documentation. Staff spoken with confirmed that they received a full report on each resident daily and read the care documentation that is kept in the main nurses station. They felt that their views were taken into account when planning resident’s care. It is acknowledged that a lot of hard work has been undertaken by the staff to implement the care plan system and improve the records and documentation and it was confirmed that training in care planning is on going. Relatives and residents spoken with were satisfied with the care provided at the home one saying that the home ‘ was very professional’ ‘ very kind and caring’. A named nurse system has been introduced and the key worker system will be introduced in the near future, which will ensure continuity of care. Records indicated that local Doctors are called regularly and are involved in the care of residents. The manager is knowledgeable about the specialist advice she can access when required such as the hospice, tissue viability specialists and dietetics. The clinical room is also the staff office; it is kept locked at all times. There is a small fridge and temperatures of the room and fridge are recorded daily. There are policies and procedures in place for staff to refer to regarding the safe administration, storage, disposal and recording of medication. The systems for recording and checking controlled drugs were found to be thorough. Medication Administration Charts were found to be competently completed. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 14 New systems are in place to track and ensure topical creams are signed for has been introduced and these are kept in folders in the residents’ rooms. Staff were seen to be respectful and considerate to all residents whilst attending to their needs. Residents are spoken to with warmth and respect and referred to by their preferred name. The residents were complimentary about the staff. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lifestyle experience by residents at this time does not always match their expectations, choice or preferences. Meals remain good in respect of both quality and variety that meets the majority of residents’ tastes and choice. EVIDENCE: The care plans still need to be developed in respect of the activities and social histories. It is acknowledged by the manager that at present the activities are not at the full potential and due to the refurbishing the communal areas are closed. The activity co-ordinator is working for 3 hours a week and in those hours takes residents out for tea on the sea front, manicures nails or spends time with individual residents. The future plans for activities will be based on the resident’s choices and desires and will include massage sessions, chair exercises and visits from musicians. More visits out will be arranged. Residents were honest in their comments and said that there was not much going on at present, but they also knew the reasons why. ‘ The home is having a face-lift Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 16 and so we don’t have the lounges yet’, ‘I do get bored, but the staff stay and chat’. Resident’s rooms were found to be individual and personalised and each resident has their preferred term of address recorded in their care documentation and this preference was respected. Residents were seen to have their choices respected through out the day with decisions being responded to. Visitors spoken to were all happy with the visiting arrangements and how staff who were said to be ‘very welcoming’ received them. There is no dining room at present and so residents eat from a small table either in their room or in the small lounge. Usual practice is that the chef serves from a trolley and residents can make their choices, this will recommence when the dining area reopens. A catering manager is in post and they have been regularly inspected by the Environmental Health Agency. The kitchen is included in the refurbishment plan and will be totally refitted. The food seen was of a high standard and with the emphasis on home cooking. Staff were seen to be following good practice when serving and distributing the meals. The chef visits all residents every morning to ask them their preferences for the day. The residents’ likes and dislikes are displayed in the kitchen and the Chef was able to demonstrate her knowledge of the resident’s preferences. The devised menus evidence a nutritious and varied diet. All feedback about the food was complimentary and comments included ‘good food’ ‘I have choices in the meals and the meals are good’. The mid day meal was observed and was seen to be organised and well managed ensuring that those residents needing assistance were given time and able to have the assistance that they needed in an unrushed manner. It was confirmed that residents had a choice at lunchtime, which included a vegetarian choice. The meals provided looked appetising and were served in a manner that ensured it looked attractive. It was however noted that food diaries are not kept at present and this was discussed with the catering manager who was advised that this should be developed to pick up dietary traits and monitor residents appetites and weight loss. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. Practice in the home ensures that complaints are responded to, with residents and representatives being confident that they are listened to. However systems for recording complaints need to be improved to demonstrate a robust procedure is followed. Practice in the home ensures that adult protection issues are responded to when identified. EVIDENCE: The complaint policy and procedure is clear and uncomplicated and a copy of this is readily available in the home and the Service Users Guide. A system of recording complaints was demonstrated to the inspector during her visit to the home. The home has not received any written complaints since the last inspection, however as discussed all verbal complaints need to be documented with an outcome and action. One complaint was directed to the home by the CSCI, which demonstrated a thorough investigation and an action plan. Relatives and residents spoken with confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 18 The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and are aware of how to initiate an investigation if required. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst Bay House is undergoing the extensive refurbishment the staff team endeavour to ensure residents benefit from a clean and safe environment. Residents and their families are enabled and encouraged to personalise their rooms, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: At present Bay House is undergoing a major refurbishment and an extension is being built. The vision for the home is to be modern and homely with the residents being consulted and involved in the process. The refurbishment obviously does impact on the outcomes for residents at this time due to communal areas being closed but steps have been taken by the whole staff team to ensure that it does not affect the residents’ safety and well-being. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 20 The newly decorated bedrooms were attractively decorated with good quality furniture and profile beds. There is an on going maintenance programme for the building, and on a weekly basis the maintenance manager and the manager or Registered Provider do a walk through check of the home and list the work to be done. There are adequate communal bathrooms and shower rooms in the home, with specialist equipment to ensure all residents can have a bath or shower. One of the newly furbished bathrooms was seen and was attractively decorated with modern fitting and a high bath with ceiling hoist. During the inspection it was noted that staff were using lifting and supporting equipment appropriately. Call bells are provided in all areas and staff were seen to be attentive and ensured residents had access to these. Good practice in respect of infection control by staff was observed during the inspection visits and there were gloves and aprons freely available in the home. Sluice and laundry areas were found to be clean and safe. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are in place to protect residents, and staff training ensures they are aware of their roles and are able to provide the support and care the resident’s need. EVIDENCE: At the time of the inspection visit 22 residents were living at Bay House. The staffing rota was viewed and details staff designations and hours of working. The manager confirmed that the staffing arrangements are flexible and respond to resident’s dependency. Staff spoken to said that there was enough staff to look after the residents to a good standard. From direct observation during the visit, the staff worked hard and were seen to be courteous and unhurried taking time to talk with residents. Staffing levels were discussed with the Manager and they need to be reviewed regularly to ensure that the refurbishment is not impacting on the daily lives of residents. Feedback received from residents, relatives and visiting care professionals as part of this inspection was very positive about the staff and comments received included ‘very friendly very nice staff I like it here I do what I want when I want to’ ‘I am very well cared for and staff are nice’ ‘I can not speak too highly of the staff’. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 22 A selection of staff recruitment files were viewed and demonstrate that a robust recruitment process has been maintained to protect residents and contained all the relevant information required. There was evidence of health questionnaires, Criminal Record Bureau checks, two references, a resume of previous employment and work permits where necessary. All the paperwork is kept within a locked room. Staff training is well established and records indicated that this is well organised with new staff starting their ‘skills for care’ induction. There was evidence that core areas of training are addressed regularly with a rolling programme, and include Medication Training, Fire Training, Health and Safety, Moving & Handling, Infection Control, Protection of Vulnerable Adults and First Aid. Other training related to the needs of the resident’s such as Tissue Viability and Caring for People With Dementia have also been undertaken. The home has a permanent care staff team of eleven care assistants, two of which are trained to a National Vocational Qualification (NVQ) level 2 in care, with a further five staff currently studying for the NVQ. Staff training records showed that staff have been provided with a range of training, including Induction Training, Medication Training, Fire Training, Health and Safety, Moving & Handling, Infection Control, Protection of Vulnerable Adults and First Aid. Other training related to the needs of the resident’s such as Tissue Viability and Caring for People With Dementia have also been undertaken. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The overall management of this home is good with effective systems in place to protect residents. EVIDENCE: The Registered Manager is a qualified Registered General Nurse and has been working in the private health sector for many years as a deputy manager and NVQ trainer. The Manager confirmed that she completed the Registered Managers Award in June 2007. The Managers job description is now in place. Residents, relatives and staff spoken with said that the Manager is friendly, Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 24 knowledgeable, and approachable and any issues raised are actioned quickly and efficiently. The Manager continues to operate an ‘open door policy’ is operated within the home, and this was confirmed by staff, residents and residents. During the inspection visits there was no doubt that the manager and the Registered Provider had a good working relationship with everyone in the home and everyone spoken to said that they were approachable and responded to issues raised quickly. The ethos of the home was open, transparent, positive and friendly. There is a clear management structure in the home with staff having designated responsibilities. Each department has its own manager, and these managers are accountable for their own concerns but are led by the manager. The Registered Provider is available full time in the home until the refurbishment is complete. Formal Quality Assurance systems have yet to be introduced within the home, but there are informal measures in use which the management evaluate the service. The Registered Provider and Manager consult with residents, staff and visiting relatives, on a daily basis to inform them of the progress made with the current building work and other matters relating to the home. Staff meetings have been implemented and conducted on a six to eight weekly basis. The monthly monitoring visits (Regulation 26 Visits) will be introduced once the Registered Provider is in less day to day contact with the home. Suitable insurance cover for the effective running of the business were noted to be in place. The homes financial procedures, accounts and business plan were viewed at the time of registration and were found to be satisfactory; therefore these items were not reassessed during the inspection. The Registered Provider reported that the home does not take any responsibility for resident’s finances and that most residents have family/representatives/friends who protect their financial affairs on their behalf. It was evidenced that formal staff supervision has been implemented. Staff spoken with confirmed this. Certificates relating to Health and Safety in the home were reviewed and found on the whole to be full. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had. The manager confirmed that she was updating all the homes policies and procedures to ensure best practice and the health and safety of staff and residents. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 25 Accidents are well documented in the home’s accident book, a new accident book has been ordered. Risk assessments are maintained for all risk areas. such as fire, external premises and building contractor/works risk assessments. Good practice was observed throughout the inspection in respect of promoting the safety and well being of the residents. Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) 12 Requirement That the care plans accurately reflect the needs of the service users in respect of their health, social and behavioural needs. That the daily personal care notes are completed. That service users and/or their representatives are consulted regarding the formation of the care plans and involved in the review process. (Timescale of 13/12/06 not met) Nutritional assessments to be completed for all residents and linked to the care plan. That daily record of individual residents dietary intake is recorded. That suitable risk assessments are completed in all areas of risk and cover the use of bedrails, risk of choking and risk of falls to promote resident safety. 3. OP12 OP14 16 (2) (m) (n) That activities are provided to suit service users expectations, DS0000067742.V351131.R01.S.doc Timescale for action 01/01/08 2. OP8 12 (1)(a) 14/10/07 01/01/08 Page 28 Bay House Version 5.2 preferences and capabilities. That service users are supported and enabled to attend activities. That a programme of activities is more formally devised based on residents choices. That residents choices are listened to and their preferences documented. That the registered person ensures that a full complaints procedure is used and that complaints are dealt with effectively and appropriate and that records are maintained to demonstrate a thorough and robust investigation, this includes verbal complaints. That staffing levels are flexible and meet the needs of the residents. That quality assurance systems are introduced. 4. OP16 22 14/10/07 5. 6. OP27 OP33 18(1)(a) 24(1)(a)( b)(2)(3) 14/10/07 01/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bay House DS0000067742.V351131.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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