Inspection on 09/02/06 for Bay Tree Court

This inspection was carried out on 9th February 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 04/07/06

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 9th February 2006 09:30 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.V281375.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 DS0000002875.V281375.R01.S.doc Version 5.1 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 (West) 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.V281375.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2005 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 care parking space. The current manager position is vacant and the deputy manager is acting up to the Manager’s position with support from the Regional team. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 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 February 2006. The records were seen to ensure that staff employed were safe to work with the people who live there and were trained to do their job correctly. Paperwork was also seen to ensure that the Company was checking the home to ensure it was safe to live and work in. A number of people who live in the home were spoken to and some staff and the Acting Manager. The Regional Manager was there for part of the inspection. The Acting Manager, Ms.D.Fell accompanied the inspector through out the visit. What the service does well: The staff were friendly and appeared to know a lot about the people who live there. The people in the home said how kind the staff always were and that their needs were always addressed. The home was clean and tidy and all checks had been completed to ensure it was safe to live and work in. The people living in the home stated that they always had choices in their daily lives, such as where they went in the home, clothes to wear, choices of meals and when they had visitors. They also are encouraged to make decisions about their home such as redecoration plans. They provided a varied menu of meals and can also provide for special diets. They are prepared in a safe and clean environment. The Company ensures that all polices are in place to ensure staff have procedures to follow for any eventuality in the home. Checks are made to ensure staff employed are safe to work in the home. All financial transactions of the people who live in the home are well recorded and receipts given. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The Company needs to ensure that all staff have received service specific training to enable them to have the information to meet the needs of the people who live there. The Acting Manager must ensure that all drug administration records are correct and that the people who live there are receiving the correct medication and it is being administered in a safe way. This will avoid mistakes occurring and people not being put at risk. The Company needs to undertake an audit of all linen supplies to ensure it is of a good standard and the people who live there are living in a comfortable environment. The Acting Manager must ensure that all staff have received supervision and the logs open for inspection. This will ensure that any needs can be addressed and the staff monitored as being safe to work with the people who live in the home. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 7 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.V281375.R01.S.doc Version 5.1 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.V281375.R01.S.doc Version 5.1 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): 4 and 5. The Company needs to ensure that service specific training can be evidenced to ensure staff have developed the skills to meet service users needs. Prospective service users are bale to visit the home prior to admission to ascertain whether it is suitable to their needs. EVIDENCE: The training records were clearly laid out and showed that mandatory training had taken place. There was little evidence that service specific training had taken place to ensure staff have the skills to meet service users needs. At the time of the inspection 2 service users were on respite admission and stated to the inspector that they were enjoying their stay. The home encourages people to visit prior to admission and does not charge for a day’s stay. This gives prospective service users opportunity to see if the home will meet their needs. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 10 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): 9,10 and 11. The drug administration records required auditing to ensure all medication was being administered safely and was what each service user required. Staff were seen to assist service users with dignity and respect. EVIDENCE: The inspector checked the drug administration sheets with the Senior Carer. There was a slight improvement in the alteration recording, but several were still not signed or with any explanation as to whose authority they had been changed. There were also some drugs which appeared not to have been given and it was explained that this had been discontinued or had not been needed for some time. Specific service users needs were fed back to the Acting Manager and she was asked to complete an audit of all drugs administered to service users to ensure they were correct and they were given what they required as prescribed by a medical practioner. Service users spoken to expressed their delight in the care they were receiving and stated that all staff treated them with dignity and respect and that their Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 11 needs were always addressed. The inspector spoke to the Regional manager at the start of the inspection and affirmed that the interim policy for care of the dying person could be implemented that day and the Acting manager was asked to ensure all staff were aware it was now in place. This will ensure that staff are aware of service users needs and that each person can be treated with dignity and respect at that time of their lives. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 12 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): 15. The home ensures that the food is prepared in a clean and safe environment and that there is a varied menu giving choice of a balanced diet to service users. EVIDENCE: The head cook, who stated that he has settled in to his role and felt supported by the local staff and the Company, escorted the inspector around the kitchen. The kitchen and storerooms were clean and tidy and the records showed that all temperature controls were monitored on a regular basis. There has been no change in suppliers since the last inspection and the head cook was satisfied with his suppliers and the quality of food supplied. The last environmental health officer’s visit was in January 2006 and the report was good. There was ample evidence of fresh vegetables and fruit and home baking. The 4-week cycle of menus was currently under review, but the head cook was able to give a good explanation of the special diets provided and how the meals are selected and served. There appeared to be ample supplies of kitchen equipment, which was all in Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 13 working order and the head cook stated he had received new supplies of crockery before Christmas. The handyman completes certain cleaning task in the kitchen which the head cook stated was a help to the kitchen staff. He also expressed that all staff were helpful and polite to his staff and appeared to work well as a team. The dining rooms were both light and airy and staff were observed assisting service users with dignity and respect. The meals were being served in a clean and safe environment and care had been taken to provide service users with a varied menu to enable them to have choice each day. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 14 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): 16,17 and 18. The Company has a robust complaints procedure in place to enable service users to have the confidence to report any matters of concern. EVIDENCE: The complaints policy was in place and the log seen. There had been 2 recorded since the last inspection and the details on file showed the nature of the complaint and the outcomes achieved. Service users stated they had every confidence in the management team in sorting out any problems and felt it would be looked into promptly and fairly. Policies were in place to show staff how to ensure that service users can exercise their legal and civic rights. The administrator offered to show the inspector details of who was currently on the local electoral role and was able to detail the process that occurs. Some were taken to the polling station and some exercised their right to postal votes at the last election. All policies were in place for the protection of vulnerable adults and staff had received training in this area of care to ensure they can identify an abuse situation and know which organisation to make referrals to, should the need arise. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 15 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. The home was clean and tidy and checks had been made to ensure it was a safe and comfortable environment in which service users can live. The home needed to complete a linen audit to ensure all bedding was in a good standard of repair. EVIDENCE: The Acting Manager escorted the inspector around the home, where all communal areas, toilets, bathrooms and a selection of service users rooms were seen. The reception area had been newly decorated since the last inspection and the new certificate was in place. This has made a very welcoming area for visitors to step into the home. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 16 The home was clean and tidy and there was evidence that others areas had been redecorated throughout the year. The individual rooms showed that service users were able to decorate them to their own taste and needs. This has helped them settle in to the home, several stated to the inspector. All equipment in the laundry area was in working order and the Acting Manager was able to describe the system of dealing with soiled linen, which appeared to meet health and safety standards. On inspecting the linen storage and trolleys, there was a need to audit the linen currently in stock, as some was not in a good state of repair. In some rooms there was a lack of valances on the beds, which made them look untidy as some bed-bases were not in a good state of repair, but were the service users’ own. An audit of line needs to take place and new bought where necessary to maintain a good stock level. The gardens and care park area were neat and tidy and free from hazards. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 17 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 and 28. The home had adequate staff on duty to ensure the needs of service users could be met and the majority had been trained to NVQ level 2 or above to enable them to do their job correctly. EVIDENCE: All rotas of staff were seen and there appeared to be sufficient in the domestic, laundry and kitchen areas to enable them to complete their workload each day and ensure the home was safe and clean and all meals could be provided. The Acting Manager has been allowed 1-2 days each week to help whilst a new manager is appointed and an administrator; a dedicated team of care staff and a Regional Company team support her. There appeared to be adequate staff on duty to meet the needs of service users and there had been no concerns raised about the level of care provision provided by the home. Service users spoken to stated that all needs were always met by the staff. The home has achieved 56 of the care staff having completed their NVQ 2 level awards and 3 more were in the process of completing their awards. This will enable them to develop the skills to deliver the practical care to service users. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 18 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): 31,35,36 and 38. The home needs to ensure that all staff have regular supervision to enable their individual needs to be addressed. All health and safety checks had been completed to ensure the home was safe to live and work in and that all money transactions had been recorded correctly. EVIDENCE: The deputy manager was Acting up to the Manager’s post, but the Regional Manager informed the inspector on the day that a new person has been appointed and will commence duty in March 2006. The Company has already written to the CSCI with details of the full support cover given to the home, which appears to meet the home’s needs. The Administrator went over all the personal allowance records of service users Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 19 with the inspector. 17 are kept on file and 3 were checked in depth. The transactions had been well recorded and receipts were seen. The Company sends an accounting person to the home to complete spot checks on a regular basis. It was suggested that this be recorded on each file. The last petty cash audit was completed in January and appeared to be correct and the residents’ fund had been checked when the last manager left. The system for supervising staff was in the process of being changed and logs were not available for the inspector to see. The Company must ensure that all staff have completed their supervision and needs identified and actioned. This will ensure they are safe to work with service users and their individual needs are being addressed and monitored. All certificates were seen to ensure the staff are checking the home regularly and it is safe to love and work in. The home sends the Regulation 26 and Regulation 37 notices in a timely manner to the local CSCI office and they each give a good amount of detail of the needs arising from them, and how the home is monitored by the Company. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 20 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 X 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 2 X 3 Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 21 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. 2. Standard OP4 OP9 Regulation 18.1.c.i. 13.2. Requirement The registered person must ensure that staff have received service specific training. The registered person must ensure that all alterations to medication records state who authorised that change. (Previous time scale of 28/02/06 not reached). The registered person must ensure that an audit of all linen supplies is undertaken. The registered person must ensure that all supervision of staff is logged and open for inspection. Timescale for action 30/04/06 30/03/06 3. 4 OP26 OP36 16.2.e. 18.2. 30/05/06 30/05/06 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 OP35 Good Practice Recommendations That the Company considers charting their auditing of personal allowance files of service users personal DS0000002875.V281375.R01.S.doc Version 5.1 Page 22 Bay Tree Court allowance money on the individual sheets. Bay Tree Court DS0000002875.V281375.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor 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.V281375.R01.S.doc Version 5.1 Page 24 - 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!