Inspection on 06/02/06 for Bay Tree Court

This inspection was carried out on 6th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 17/07/06

Bay Tree Court 25/10/05

Bay Tree Court 02/11/04

Bay Tree Court 08/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor 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 Bay Tree Court High Street Prestbury Cheltenham Glos GL52 3AU Lead Inspector Mrs Janice Patrick Unannounced Inspection 6th February 2006 11:25 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 DS0000016383.V278278.R01.S.doc Version 5.1 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 DS0000016383.V278278.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bay Tree Court Address Bay Tree Court High Street Prestbury Cheltenham Glos GL52 3AU 01242 236000 01242 244576 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) European Healthcare Group plc To be appointed Care Home 59 Category(ies) of Old age, not falling within any other category registration, with number (59) of places Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Baytree Court is a purpose built care home situated in the heart of Prestbury Village, which is on the outskirts of Cheltenham Town. It is convenient for local shops, the post office and a public house. It has its own designated parking within well-kept grounds. The Home offers both personal care and nursing care to those over 65 years of age. Spread out over two floors, those requiring nursing care are predominantly cared for on the first floor. This area has a keypad entry. The ground floor is mainly designated to those that require personal care only. Both areas offer well appointed, single accommodation all with en suite facilities. There are ample communal rooms and bathing facilities. The Home and its grounds are wheelchair friendly. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one Inspector between the hours of 10:25am and 1pm. The Acting Manager and the Senior Care Co-ordinator were on duty amongst other members of the Home team. Several residents were spoken with to obtain their view of the Home and the food. The medication system on the ground floor was inspected. Catering arrangements were discussed and a sample of menus seen. Residents’ personal monies and associated records were inspected. Other documentation and records seen included resident assessments prior to admission, staff recruitment files and plans for staff training. A selection of quality assurance questionnaires were also seen. What the service does well: What has improved since the last inspection? The Registered Manager is now fully based at the Home after a period of also managing one of the company’s sister Homes. A member of staff has been chosen to commence as the Deputy Manager and the company have employed a Clinical Operations Manager to support all their Registered Managers. A new Catering Manager is also in post. Both menus and how the food is being served have been reviewed. This process has actively involved the residents. Agreements are in place to increase the staffing levels at night from March this year. All residents in the Home have had their needs fully reviewed by the Manager. Care planning documentation has been reviewed and the process of updating all care documentation is in progress. There is a structured programme of staff training. Formal staff supervision has recommenced. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 6 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. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 7 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 DS0000016383.V278278.R01.S.doc Version 5.1 Page 8 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&6 The assessment process used in this Home ensures that staff are aware of the resident’s needs prior to their admission and therefore ensures they are adequately met once they are in the Home. This Home does not provide dedicated intermediate care. EVIDENCE: The pre admission assessments of four residents were read. One was not in the Home’s own assessment format but included comprehensive information from external health care professionals. This had been faxed to the Home as the resident was being admitted from another county. Another internal pre admission assessment had been carried out and all areas assessed were recorded as ‘normal’. This does not give concise information to the reader but the Senior Care Co-ordinator was very aware of this individual’s needs. Another did not have a date but the Senior Care Co-ordinator could remember when this had been completed. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 9 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): 9 The systems for medication storage and administration are good with clear and comprehensive arrangements in place to ensure residents are not placed at risk. EVIDENCE: During this inspection the medication system on the ground floor was inspected. General storage was organised and appropriate. A few gaps were seen on the administration records (MAR Sheets). Photographs of each resident were in place to aid identification. A minor shortfall was identified where handwritten instructions on the MAR Sheets must have two signatures to avoid mistakes in transcription. The present British National Formulary (BNF) is dated 2003. Appropriate signage was seen in place for the storage of oxygen. The planned review of one resident’s medication was discussed. The Senior Care Co-ordinator said that she regularly audits the system, but this is not recorded as part of a formal quality assurance audit as yet. Only staff who hold the Safe Handling of Medication Certificate administer medication on this care floor. If no one on duty holds this certificate then a qualified nurse from the nursing floor will complete this task. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 10 Care planning was discussed and a sample of the new documentation seen as a follow up to a requirement made in the previous inspection report. This has been partially met on this floor. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 11 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): 14 & 15 Residents are helped and supported to make choices and have some control over their lives. The catering in this Home is improving and there is evidence to show that residents are being heavily involved in the reorganising of menus and delivery of food. The nutritional needs of the frailer residents are being met. EVIDENCE: Through talking with residents, inspecting records and observation it was clear that residents are helped to make choices and maintain some control over their lives. Many of the bedrooms have the resident’s own pieces of furniture and belongings in them. Records show that residents have varying degrees of control over their money according to their abilities. This may include support from their family or the Home administrator. The Inspector spoke with one resident who enjoys walking into the village and dealing with some of his affairs in the local post office. During the last inspection external caterers were responsible for the Homes catering. Responsibility for this has now reverted back to the Home and is the prime responsibility of the new Catering Manager who commenced in post in Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 12 December 2005. The Home is currently recruiting a new Chef and kitchen assistant. The minutes of a residents meeting held on 31/01/06 record discussions with residents about the menus and how the food is served. On talking with the ground floor residents at lunchtime, it was clear that the Registered Manager had been involving them with menu choice and listening generally to their views on the subject. The Inspector spoke to 9 residents in the dining room and none could remember what they had chosen the day before for their lunch. It was recommended that the choices be written up on the day as a reminder. General comments were that the food is improving. The Inspector did observe bread and butter being served by one of the staff members by using her fingers. The Manager confirmed that the food being served to those that require a soft diet is meeting their nutritional requirements. The problems arising with this on a Sunday teatime, when a buffet style tea is served, have been addressed. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 13 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): 18 Residents’ safety will be enhanced once staff have received updated training on adult protection. EVIDENCE: The standard was discussed as a follow-up to a requirement made in the previous inspection report. The training programme for the Home was seen and training in Adult Protection and Elderly abuse were planned but had not yet commenced. It had been identified that more sessions than those allocated already would be required to ensure all staff received this training. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 14 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, 20 & 24 The standard of the communal areas and of the private bedrooms is good providing residents with an attractive and homely place to live. EVIDENCE: The lounge and dining areas were clean and attractive during this inspection. There were no offensive odours on the ground floor of the Home. Individual bedrooms varied from looking extremely personalised and ‘lived in’ to just having the furniture and soft furnishing that are provided by the Home in them. The Registered Manager confirmed that there is a rolling programme of maintenance and decoration and planned for 2006 is the decoration of the dining room. Colour schemes are at present out for consultation with the residents. It is also planned that the furniture in 10 bedrooms will be replaced. New admissions to the Home and other residents if they wish will be able to choose the colour scheme of their bedroom in the future. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 15 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): 29 The standard of vetting and recruitment is high therefore providing protection for the residents against poor practice or abuse. EVIDENCE: The progress so far in relation to the recruitment of a Chef and kitchen assistant was discussed. The file of a new recruit employed since the last inspection was seen. All the criteria set out within the Care Home Regulations 2001 had been met prior to her employment. All Criminal Record Bureau (CRB) clearances were seen and signed off at this inspection. All records and information pertinent to this standard are stored securely therefore meeting with Data Protection guidelines. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 16 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): 33, 35 & 38 The systems for resident consultation are good in this Home with a variety of evidence that indicates that resident’ views and ideas are both sought and acted upon, although aspects of this system need further development. There are robust arrangements in place to ensure the safety of residents’ monies and help protect them against financial abuse. Residents benefit from living in a Home that is well maintained and where there is safe practice. EVIDENCE: The Quality Assurance system was discussed and although there is active consultation with residents there is as yet, no formal auditing taking place. This has been identified as needing to be developed in order for the management to measure how effective its systems are and the standard of care being provided. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 17 Development of this will help the management complete the self assessment form that will be required by the CSCI as part of the future inspection process and help them devise their annual development programme, which will also be required. The systems, which ensure residents’ monies are kept safe, were inspected. All records seen were correct. Residents have a varied way of running their ‘in house’ accounts. One resident has an arrangement with the administrator where the family leave a cheque, which is cashed for the resident by the administrator. When cash is then required by the resident the administrator brings this to her and maintains the Home’s record as the resident’s eyesight is poor. This process is carried out with a second witness of which signatures were seen on the records to verify this. Another example involves the Power of Attorney sending monthly amounts of money to the administrator. She then ensures such bills as chiropody, hairdressing and newspapers are paid on behalf of that particular resident, but the resident never requires actual cash. All ‘in house’ accounts held have a reconciliation statement quarterly which either goes to the resident, family and/or the Power of Attorney. Access to monies and these records is limited to the resident or representative, the administrator and the Manager only. Some residents manage their finances independently or with the help of their family, therefore the administrator does not get involved. The maintenance person was not on duty when this standard was inspected therefore; previously seen records were not inspected on this occasion. However, the Senior Care Co-ordinator was able to confirm the following, that the temperature of the hot water is checked and recorded on a regular basis, that smoke detectors were checked the week before this inspection, that the fire alarm is checked weekly, that a recent sight check was carried out on all moving and handling hoists on the ground floor and that these are regularly serviced by a recognised contractor. She was also able to confirm that moving and handling training for staff is ongoing and that some staff still require an update. Planned training sessions for this were seen by the Inspector and the Manager, who is a trained moving and handling trainer, is at present working her way through the staff group to update them. Records have been seen during each previous inspection and the Inspector is aware that the Home adheres to any recommendations made by the Fire Officer. At the time of this inspection the acting Manager’s application for Registered Manager of Baytree had not been received by the CSCI. It has subsequently been received and the process of formally registering the acting Manager has begun. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 18 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 3 X X X 3 X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 19 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 Requirement The Registered Manager must ensure that relevant and updated care planning is in place for all residents identified needs. The Registered Person must ensure that two signatures accompany any handwritten instruction on the MAR Sheets. The Registered Person must ensure that all staff have knowledge of the Homes Adult Protection Policy/Procedure and receive updated training on this subject. The Registered Manager and Registered Person must devise a system that evaluates and aims to constantly improve the care and services provided by the Home. The Registered Manager and Registered Person must submit to the CSCI a report on the review required within requirement 4 (above). This must be in consultation with residents/representatives and a summary of the report made available to them. DS0000016383.V278278.R01.S.doc Timescale for action 14/03/06 2. OP9 13(2) 01/03/06 3. OP18 13(6) 01/06/06 4. OP33 24(1)(a)( b) 01/05/06 5. OP33 24(2)&(3) 01/09/06 Bay Tree Court Version 5.1 Page 20 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 OP15 Good Practice Recommendations That the menu for the day be written out to help remind the residents what it was they chose the day before. Bay Tree Court DS0000016383.V278278.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 DS0000016383.V278278.R01.S.doc Version 5.1 Page 22 - 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. 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