Inspection on 04/07/06 for Bay Tree Court

This inspection was carried out on 4th July 2006.

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 Tree Court 29/06/07

Bay Tree Court 09/02/06

Bay Tree Court 09/11/05

Bay Tree Court 02/03/05

Bay Tree Court 30/09/04

Bay Tree Court 03/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Bay Tree Court Normanby Road Scunthorpe North Lincolnshire DN16 2AR Lead Inspector Theresa Bryson Unannounced Inspection 4th July 2006 09:00 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 Tree Court DS0000002875.V303220.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 Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bay Tree Court Address Normanby Road Scunthorpe North Lincolnshire DN16 2AR 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) 01724 855410 01724 853735 Southern Cross Healthcare Service Limited Position Vacant Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Baytree Court Care Home provides care for 34 service users under the category older people. It is owned by the larger company Southern Cross Ltd and has the full support of a head office and regional team. The Regional operations manager makes regular visits. It has sister homes in near by Grimsby. The home is situated on the very edge of the main town thoroughfare of shops in Scunthorpe and bordering a residential and hotel area and small industrial estate. The home is purpose built and has gardens to the back and sides. All areas are accessible for wheelchair users and there is ample car parking space. The current manager position is vacant and the Regional team and other local home managers in the Company support the home. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in July 2006. Prior to the visit 10 questionnaires were sent to relatives of people who live in the home, of which 8 were returned and 10 questionnaires to staff, of which 3 were returned. 8 questionnaires were completed by people who live in the home, on the day of the visit, 4 people were spoken to who live in the home and 8 staff were spoken to and 2 visitors on the day. 2 relatives were spoken to by telephone prior to the visit and 2 members of the local authority social services team. The inspector was trying to get a balanced view of what people felt about the home and the staff who work there and the care bring received. The inspector also took into consideration Regulation 26 notices sent to the local CSCI by Company representatives in the past year; Regulation 37 notices sent to CSCI from the home concerning deaths and other serious events and also the event history over the last 8 months. 2 complaints had also been recorded by CSCI since the last inspection and the outcomes read again prior to the visit. The Acting Manager Ms.M.Pepworth accompanied the inspector throughout the visit and the Director of Operations for this area of Southern Cross was spoken to by telephone. What the service does well: The staff at the home are always welcoming and friendly and willing to speak about the home and how it functions. All staff appeared to approach the people who live there in a calm and quiet manner and treated each one with dignity and respect. Many positive comments were received by the inspector about the caring attitude of all staff. The gardens are always neat and tidy and have several sitting areas around the building. The outside area is free from hazards and makes a pleasant environment for the people who live there to enjoy some fresh air. The people who live in the home are encouraged to personalize their own rooms and given every assistance to do this to suit their needs and tastes. This helps each person to integrate into a new setting and encourages feelings of belonging. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 6 The Company will always give advice and support at all times from the Regional and Head Office team and other local managers give practical support, when required. This ensures the staff feel part of a larger, supported Company and the people who live there will always have someone to share their concerns and worries. What has improved since the last inspection? What they could do better: There was a lack of evidence to show that staff had received training in specific topics, which current people living in the home were suffering from, such as diabetes and dementia. Without this type of training the people could be at risk from being looked after by ill equipped staff, with a poor knowledge base of the latest methods of care. The records kept on each person living in the home were at times poorly written. Not every event had been recorded, which did not give an accurate picture of the care being delivered to each individual. This could result in not all needs being met for each person. The records kept on individual activities were very clear and showed how each person had taken part in various events, but there was little recorded about how people interact with the local community and who visits the home on a regular basis. As this is an individual’s home they have the right to know about events and can then choice whether they wish to take part. Several people living in the home, some relatives and staff were unhappy about the staffing levels in the home on a daily basis. The manager was reminded that she should ensure the dependency needs of each individual have been checked and that there are adequate staff on duty at all times to meet everyone’s needs over a 24hours period. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 7 Records were also checked for the safe keeping of the peoples’ personal allowance funds, the residents’ fund, petty cash fund and the trolley shop, (which opens in the home weekly). The manager was asked to complete an audit to ensure that the paper and computer records were correct and the money held in both cash and bank account format were absolutely correct. This will ensure that no one is suffering from any financial abuse and that all parties having access to this money are keeping accurate records. Since the last inspection the high standard of cleanliness and tidiness in the home had gone down. This was remarked upon by several people living in the home and other visitors. People living in the home want to feel and need to live in a safe and comfortable environment, which at the moment they had stated was not so. The regional operations manager had already identified a need for deep cleaning in the kitchen area, which the cook was aware of, but during the course of this inspection other areas were highlighted for attention, such as paper packets of ingredients needing to be in sealed containers and condiments on tables needing to be cleaned, as they were sticky. Food must be prepared in a clean and safe environment and the people living there need a balanced menu to choice from each day. The provision of linen and this being in a good state of repair had been identified at the last inspection and had still not been satisfactorily completed. Some items, such as towels were frayed and some sheets looking very thin. This does not make for pleasant surroundings and makes each room appear uncared for. 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. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 8 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 Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 and 6. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective service users are assessed prior to admission and comprehensive documentation prepared so staff can prepare fully for the person’s admission. EVIDENCE: The pre-assessment documentation provided by the company had been fully completed on the 4 care plans tracked. Needs and problems were then formulated onto further records to ensure that initial needs were being met. Care plans were then seen to be evidenced after all needs had been identified, which staff were advised to up date on a minimum of a monthly bases or as the need arose for some, such as wound care problems. There was provision, which was being met that service users have as much input into how care is delivered to them, and signatures were seen to this effect. Service users spoken to also stated they were asked frequently about their needs. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 10 The service users guide provided to all prospective service users and their families clearly states the type of service the home can provide. This helps individuals to assess whether the home is suitable to meet their needs. There was a lack of evidence to support that enough service specific training had taken place since the last inspection to ensure staff are fully up to date with the latest practises to meet all needs. This requirement remains outstanding from the last inspection. The home does not provide intermediate care and therefore NMS 6 is not applicable. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. Comprehensive care documentation was provided by the company for all service users, but more attention to detail was required to ensure staff are aware of all current needs of service users. The medication records showed that drugs were being given safely by fully trained staff. EVIDENCE: 4 care plans were tracked in detail during the course of the visit and 4 service users spoken to on the day. The documentation provided by the company was comprehensive and would ensure that staff have written information about all service users. The manager needs to be aware that not all needs were being identified on the care plans and that staff were not always following through events that had happened on the correct documentation. For example it was written that one Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 12 person had received an injury to their arm, which relatives had noted, but this was not followed through on the accident documentation or daily report. One service user stated that she had requested two baths a week, but was only receiving one, which had not been recorded or amended on her care plan. It was fed back to the manager that there should be better recording in the daily report sheets, these were spasmodically written in places and did not give a full and accurate picture of the care being delivered on a daily basis. This could result in the needs of service users not being met. The recording by staff of visits by and to health care professionals was again spasmodically recorded. This evidence was from information received by relatives and service users in written survey forms and by checking their concerns in the care plan documentation. For example a visit to a hospital appointment had not been followed through resulting in a family travelling a considerable amount of miles unnecessarily to the home. On another occasion a GP visit had not been recorded although the service user was able to inform the inspector when the last visit had occurred. The manager was reminded that all information needs to be accurately recorded to ensure staff are aware of each person’s up to date needs and any instructions given by other health care professionals. The drug administration records were all checked and found to have correct recording for each item. This has greatly improved since the last visit and all changes had been correctly recorded on the administration sheets and care notes. The senior carer assisting the inspector at this time was able to give a comprehensive account of how ordering and receiving drugs is completed in the home. The storage room was a little warm and although the temperatures of this room and of the drug fridge are taken they are rarely recorded. The manager was advised that this is good practise to maintain temperature control for the storage of medication and was started immediately. All staff administering medication have completed a safe administration of drugs course and written evidence of these courses was seen. The home has a robust policy in place and the staff appeared to be using safe practises when administrating drugs to service users. On the paper surveys received from service users and their families and on speaking to service users on the day, they all stated how caring the staff were to them. They also stated that they felt they were always treated as individuals and had all their needs met. According to the written records the needs provided for in the home are diverse and range from those who require all care being given to those who only need minimum supervision. Some service users were able to name their key worker and one stated,” she remembers my birthday and what are my favourite flowers and sweets”. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 13 Staff were observed assisting service users in a wide range of activities during the day and always appeared calm and treated each person with dignity and respect, addressing them as they wished and knocking on doors for example. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. The activities provided by the home matched some of the expectations of the service users, but there was little contact with the local community and communication between staff and relatives was poor at times. The menu needs to be revised to ensure it is appealing and provides a balanced diet, and that it is prepared in a cleaner environment. EVIDENCE: The activities records provided showed that the activities organiser takes time to write an entry each time a service user takes part in an activity, even when it has been an informal chat. It also detailed how the person took part in each activity, for example that they fully participated in a game of dominoes. These sheets are then used by the key worker for each service user to build an ongoing picture to ensure each person’s social, recreational and cultural needs are being met. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 15 There was little evidence to show that the service users have much contact with the local community and this needs to be expanded upon to ensure they feel part of the community they are living in. Some relatives and service users themselves stated how they were able to bring their own belongings in with them on admission and this had helped them settle into the home. One person stated how, as a local artist she was able to advice the staff how she wished to have her own paintings displayed and often advices on the picture collages on display around the home. The cook was present during the tour of the kitchen. He was aware that a recent Regulation 26 notice to CSCI had stated by the area manager that the kitchen needed a deep clean and that quotations were being discussed with the manager. Some areas needed a thorough clean and some paintwork was also very scruffy. It was also pointed out that there were several opened packets of cooking items in the storeroom, which required to be in sealed containers, which the manager stated would be rectified immediately. 5 service users stated in their written surveys that the choices of meals and how they were presented had slipped in recent months. The same set of 4 weekly menus were seen, which had been in use over the last two inspections. The manager stated she was looking at these and would be surveying service users as to their likes and dislikes. The dining areas had been well maintained, but required more attention to detail, for example the condiments on the tables were sticky and tops dirty and some tablecloths had not been ironed very well. Staff were seen to assist those service users, who required it, in a calm manner and the main lunch meal of the day appeared to be unhurried. Although the dining areas were light and pleasant, there needed to be more attention to detail to make it a more relaxed environment and service users need more choice to receive a balanced menu which needs to be prepared in a clean and safe environment. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The management team at the home deals with complaints promptly and service users had confidence that their concerns would be dealt with efficiently. The Company needs to ensure that all staff have received training in the protection of vulnerable adults to keep the service users safe from abuse. EVIDENCE: 2 complaints had been received by the CSCI since the last inspection. These had been dealt with by the Provider and the outcomes were partially substantiated concerning training of staff and managerial support. These matters had been dealt with prior to this visit and all unmet Regulations had now been met. 2 complaints were also seen to be on the complaints log, in the home, which had been dealt with internally and these recorded a satisfactory outcome for each service user. 3 other people had raised concerns in the home, but stated that these had been dealt with promptly by the management team. Service users and staff spoken to on the visit all stated that the new Acting manager was very approachable and they felt would deal with any problems and concerns in a professional manner. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 17 The complaints process was on display and the policy appeared to be robust. The training records for staff clearly indicated which had received update training in the protection of vulnerable adults, which could put service users at risk from abuse. All other processes to protect service users from ill equipped staff, such as criminal investigation bureau checks and the recruitment processes were very robust, as the polices and evidence in the staff files tracked showed. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Areas of the home had not been well maintained and quality checks by the previous management team had not been robust enough to ensure service users were living in a safe and well-maintained environment. EVIDENCE: The Acting manager accompanied the inspector on a tour of the building. There had been some new refurbishment since the last inspection, but the main corridor carpet upstairs was due to be replaced in the next couple of months. Progress could be checked on the maintenance and renewal programme submitted for 2006/07.This detailed areas of the home to be checked and detailed floor coverings, walls, paintwork, soft furnishings and accessories. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 19 Parts of the home were looking shabby and scruffy and there was a lack of attention to detail. For example the bathrooms generally were very untidy, with broken, unlabelled items stored in corners, tiles off the walls, (which were in the same condition at the last inspection), hoists needed a deep clean to ensure they were safe for use for service users, who could be prone to infection from being in contact with unclean surfaces. The sluice areas of the home needed a deep clean and any items such as badly stained urine bottles or bowls discarded. These were not pleasant areas for staff to work in, in their present state. 2 of the written surveys returned to the CSCI from relatives and service users stated they felt the standard of hygiene had dropped in recent months. This was certainly evident in the lack of attention to detail of tidiness in the home, since the last inspection. Some rooms had dusty window ledges and TV screens and in some en-suite facilities there was dust on the toiletries and personal items stored. This untidy and dusty environment was not conducive to service users living in a relaxed and well-maintained environment. The understair areas were being used as storage, which contravenes the fire precautions in the home, this has not happened before and the Acting manager was in discussion with the handyman as to the best place for items to be stored. She had also identified that the linen audit which had taken place to correct the unmet Standard 26 from the previous inspection had not been robust. On examination of the linen cupboards and bed linen and towels in rooms, some was in a poor standard of repair. The lack of attention to detail in the home, possibly because of a lack of continuity of leadership has made service users and their families feel uneasy about their living conditions and some were upset that this had happened and were reluctant to recommend the home to family and friends needing residential care. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. Staffing levels need to be reviewed to ensure there are adequate numbers of staff on duty to met all service users needs at all times. Recruitment practises are robust and staff trained to do their jobs. EVIDENCE: The manager stated that recruitment for more care staff was in progress as there had been several staff changes in the months prior to her appointment, for a variety of reasons. This has left a shortfall and permanent staff have been supported by agency staff. Staff stated in written surveys and verbally to the inspector that they would not like this situation to continue for any length of time, but each person was trying to support each other, which was to be commended. The written surveys sent in by service users and relatives, and those service users spoken to on the day all stated that they felt the reduction of staff, particularly in the morning, was affecting the care delivered to each person. The manager was asked to re-evaluate these levels and reassess each person’s dependency level and adjust the staffing appropriately. Particular attention was needed for the morning and night shift as these areas were identified by users Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 21 of the service, relatives and staff as the time when needs are most difficult to complete. 4 staff files were tracked in depth and found to have all the necessary documentation to ensure prospective staff were safe to work with service users prior to employment. Each file also contained an interview checklist to decide if each person would be suitable for employment by the Company. No evidence could be produced to show how many staff had completed their NVQ training or were currently completing. The training records on some files had been spasmodically completed. The inspector was given the latest training statistics for the home, which had been prepared by a Company representative. This indicated that the majority of staff had completed mandatory training and very few service specific training. The majority of staff had completed moving and handling training; fire and all staff administrating medication had completed their training. Staff need to have all the latest training in place to ensure that they have the best knowledge base to address any problems identified by service users and can respond promptly to needs. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38. Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. The home requires consistent leadership to ensure that the service provided meets the needs of service users and the environment is safe to live and work in and staff have adequate supervision to ensure they are safe to work with the service users. EVIDENCE: The home currently has an Acting Manager in place who is applying to be registered with CSCI. She has identified priority areas to look at in the home and also registered for her Registered Manager’s Award. Several people visiting the home on the day of the visit stated that the atmosphere had changed since her arrival and service users and staff stated they found her approachable and already had addressed some minor issues promptly. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 23 The home currently has the Gold Award, given by the local authority quality assurance team for excellent services provided to service users. A new assessment had just been arranged to review this status, but staff appeared hopeful they would maintain the current level. The inspector was also given a copy of the last home audit, completed by another home manager for the Company in June 2006. The home had obtained 91 of a total score of 100, bringing them into the highest category the company can award. An action plan for the manager to follow was also submitted. This assures staff that all aspects of running the home are looked at on a monthly basis and any corrections can be corrected promptly. Some service users stated they had been asked their opinions and felt they Company was listening to them. The area manager is very prompt in sending Regulation 26 notices and aspects have been challenged by the inspector and found that action, as stated had occurred. For example the last one identified a cleaning problem in the kitchen and deep-cleaning quotations from suppliers had been obtained, as stated. The administrator assisted the inspector in checking the personal allowance funds of service users. 3 were tracked in depth and all records were correct. She stated that the home also has a petty cash system and a residents’ fund. These balances were not checked, but records were seen for both systems. The Acting manager needs to ensure that all these balances are correct, as she had not checked them since being employed, two weeks previously and there was a lack of signatures for the residents’ fund. There was no evidence to support that any head office staff had also checked these balances and the administrator thought it was a year ago. The inspector also raised concerns that no one appeared to know how the trolley shop, run by the activities organiser, was funded, what happened each time it was used and how items were purchased for sale. The residents’ fund showed entries where money had been paid in from the trolley shop, but there was no specific pattern to the entry dates. The Company is required to ensure that all accounting and financial practises are sound, that all transactions are logged and are traceable, to ensure that financial abuse of service users cannot and does not occur. The supervision records were seen and although slightly behind schedule the manager was hopeful that supervisors would be able to catch up on these in the forth-coming months. This ensures that staff are monitored that they can do their jobs correctly and any areas of training or like of skills can be actioned. Records were seen to ensure that the Company is ensuring the home is safe to live and work in. All maintenance certificates appeared to be up to date and Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 24 the handyman appeared to know what was expected of him for regular auditing checks. The last sets of minutes of meetings were also submitted to show that the company is keeping staff apprised of issues in the home and they are given the opportunity to raise concerns. These included minutes from kitchen, relatives, management, housekeeping and activities meetings. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 25 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 X X 3 2 X N/A 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 3 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 3 X 3 Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 26 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 OP4 Regulation 18.1.c.i. Requirement The registered person must ensure that staff have received service specific training. (Previous time scale of 30/04/06 not met). The registered person must ensure that all care plans are up to date and all events accurately recorded and these are audited. The registered person must ensure that the service users have regular contact with the local community. The registered person must ensure that the meals offered give a balanced diet, which is prepared in a clean environment. The registered person must ensure the environment is clean and well maintained and a programme of maintenance and renewal produced. The registered person must ensure that an audit of all linen supplies is undertaken. (Previous time scale of 30/05/06 not met). Timescale for action 30/12/06 2. OP7 15.2.a.b. 30/09/06 3. OP13 16.2.m. 30/12/06 4. OP15 16.2.h. 30/09/06 5. OP19 23.2.d. 30/09/06 6. OP26 16.2.e. 30/09/06 Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 27 7 OP27 18.1.a. 8. OP35 25.3.a. The registered manager must ensure that there are sufficient staff on duty to meet the needs of service users at all times. The registered person must ensure that records are open for inspection for the safe running of the personal allowance accounts of service users, the residents’ fund and the trolley shop. 30/09/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is good practise to keep a written record of the room temperature in the drug fridge and drug room storage area. Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 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. Extracts may not be used or reproduced without the express permission of CSCI Bay Tree Court DS0000002875.V303220.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!