Inspection on 09/11/05 for Bay Tree Court

This inspection was carried out on 9th November 2005.

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 29/06/07

Bay Tree Court 04/07/06

Bay Tree Court 09/02/06

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 November 2005 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.V264435.R01.S.doc Version 5.0 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.V264435.R01.S.doc Version 5.0 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 Ms Sharon Patricia Smith Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2005 Brief Description of the Service: Baytree Court Care Home provides care for 35 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 has a professional nurse background and a team of care staff, full domestic and catering team, activities organiser, handyman/gardener and administrator, supports her. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in November and was unannounced. To find out how the home was run and if people who lived in the home were pleased with the care they got, the inspector spoke to the manager, 7 service users, 8 staff, the Regional manager and Regional director of operations for the Company. Paperwork kept in the home was also seen to make sure that checks to make sure staff are safe to work in the home had been done. And that they had been trained to do their job safely. Paperwork was also looked at to make sure the home and the things it were safe and checked often. The manager for the home Mrs.S.Smith accompanied the inspector for the whole visit and they were joined over the lunchtime period by the Regional manager and Regional Director of operations for the Company. What the service does well: The staff looking after the people were very friendly and knew a lot about each person. They showed dignity and respect to each person when they approached and assisted them through out the day, in a variety of tasks. The home was clean and tidy and had lots of space where people sit and relax or eat. The people who live in the home spoken to said how helpful and caring the staff were to them. The paperwork given to people before they come in to the home is clearly written and details all the services the home provides. The records kept on the people who live in the home was detailed and showed what care each person had received and how their needs were met. The activities provided by the home allowed the people who live there to maintain contact with their families, friends and the local community and to Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 6 satisfy their social, cultural, religious and recreational needs. The environment in the home was well maintained and the people who live their asked their opinions for redecoration of communal areas and their own rooms to suit their tastes and needs. The home provides staff who are checked and trained to ensure they are safe to work with the people who live there. The company provides a quality audit tool to ensure the home is checked on a regular basis and is safe to live and work in for the people who use it. What has improved since the last inspection? What they could do better: The manager must ensure that any changes to a persons medication records show who authorised the change and when, to ensure all medication is given safely to the people who live there. The following policies need to be revised by the company to be sure they follow the latest legislation and current guidelines; - care of the dying person, allowing people to exercise their legal and civic rights and the policy to protect the people from abuse. These remain outstanding from the last inspection and Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 7 should be given priority by the Company to ensure the staff who work there have a sound knowledge base and are safe to work with the people who live in the home. 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.V264435.R01.S.doc Version 5.0 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.V264435.R01.S.doc Version 5.0 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): 1,2, 3 and 6. Service users are provided with comprehensive documentation before entering the home, to enable them to make informed choice. Staff are given preadmission paperwork to enable them to adequately prepare for a person’s admission. EVIDENCE: The pre-admission documentation has been revised since the last inspection and is now in 16 sections giving an holistic overview of the care a prospective service user needs. Also included is an admissions checklist to enable the administration staff and manager to see whether all parts have been completed. This will then ensure staff have full details on that person to commence a care plan, best suited to their needs. Either the manager or her deputy completes this, but she can be supported by the Regional manager or other mangers based locally if the need arises. The statement of purpose and service users guide remain unchanged since the last inspection and give a prospective service user informed choice of all the Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 10 services the home provides. There is a section on the admission checklist to say when they had received that documentation. The home does not provide intermediate care and therefore Standard 6 is not applicable. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 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 11. The company provides comprehensive care documentation to enable all service users needs to be monitored and assist the staff to deliver the appropriate care to each person and administer all medication correctly. This documentation had not been completed correctly in some cases. The company has failed to revise a policy required at the last inspection. EVIDENCE: The company had introduced some new care plan documentation since the last inspection and the staff are working their way through each person’s care plan in a methodical way. 75 had been transferred over at the time of the inspection. This documentation should enable the staff to create a detailed plan for each person and also use supplementary paperwork for specific problems such as injuries after a fall, diabetes control and monitoring after an accident. 4 care plans were tracked on the day. The care plans were clearly written and it was ease to track the actual delivery of care through the writing of the key Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 12 workers. There were a few gaps in the documentation where it was difficult to ascertain the input the service users had had in the planning of their care. The home needs to ensure this is documented clearly. Most service users spoken to were aware records are kept on them and some stated they had seen those records. The company has a system in place to ensure these are audited on a regular basis. The Regional manager states on the Regulation 26 notices sent to the local CSCI office what she has seen, the manager completes a monthly audit sheet and the deputy manager audits three each week. All audits are recorded and seen by the inspector on the day. This ensures that the needs of each person are being addressed and senior staff are monitoring the actual care delivered. A senior carer escorted the inspector around the drugs cupboards and was able to describe the system in place. The room was tidy and drugs trolleys clean. All staff administering medication have completed a suitable course to enable them to be safe practioners. All medication sheets were seen and there had been alterations to the transcriptions, which did not identify who had authorised them and when. Staff must ensure this is recorded so medication can be given safely to each person. It was also noted that there had been some bad stock control for one person’s medication, which the manager was made aware of on the day. The medication policy was on display and there was an up to date reference book for staff to also use, if they needed to refer to a new drug. The policy for caring for the dying person had still not been revised by the company and needs to include the latest legislation and local guidelines. This will enable staff to have the knowledge base to care for some one appropriately in the later stages of their life. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 13 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 and 14. The home provides a varied programme of activities, which satisfies their social, cultural, religious and recreational needs. EVIDENCE: The activities organiser was spoken to on the day of the visit and was able to describe his role and his empathy with the service users due to his own disability. He keeps his own records of activities, which were produced and showed events taken place, whether the session was a group one or one to one and any staff involvement. He also will record how the service user took part in the event, for example how they liked the event and their level of participation. This enables staff to see what is required for each person and also whether any changes take place in the service users ability and desires to take part in recreational activity. Seen in the care plans tracked were the social needs assessments and profiles of each person. This is completed by the key worker and gives staff a basis to plan events for each service user. The activities plan seen was very varied and covered events both inside and outside the home. Memories of these are recorded in photographic format and displayed in the corridors round the room, which service users stated they are Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 14 proud to show to their families. There was also a lot of recorded events with the local community, both coming in to the home such as the local churches and going out for example to events at the local library. Service users stated this makes them feel a part of the local area and occupies their days. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 15 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): 17 and 18. There was no robust policy in place to ensure service users legal rights were being maintained and that they are protected from abuse. EVIDENCE: The company has still failed to revise its policy for ensuring that service users legal and civic rights can be exercised. The manager was able to produce documentation to show that all permanent service users are included on the local electoral role, but the policy needs to include how they can exercise this right. The policy for the protection of vulnerable adults is a broad company policy and does not include the local guidelines, especially for referral purposes. The topic is covered in the induction of all new staff and revised yearly for all staff, this is recorded on their training records. Failure to have up to date policies in place could result in service users being placed at risk from abuse. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 16 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): 19,21 and 26. The home was clean and tidy and the environment safe for this category of service user. Planning and redecoration and refurbishment of the home was evident. EVIDENCE: The maintenance plan for the home was on display in the manager’s office and was valid until September 2005. The next year plan ahs been submitted and will include any unfinished areas on the previous year’s plan. The manager escorted the inspector on a tour of the home where all communal areas, toilets and bathrooms were seen and a selection of bedrooms. All areas were clean and tidy and some had been redecorated since the last visit. This included; - the smokers lounge, several bedrooms, hairdressing salon and the upstairs lounge. In the latter room the service users sitting in the room stated they had chosen the colour scheme. Carpets had been replaced in some rooms and the downstairs corridor carpet was new. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 17 One bathroom was still out of action, but this was not the fault of the home, but the supplying company for a new bath panel, who since the last inspection had made several mistakes. The manager could produce documented evidence to show that the home’s parent company were trying their utmost to rectify the situation. The bathroom is not needed as the home has the required number of bathing facilities for the number of service users at this time. There was ample evidence that service users can personalize their own rooms, which those spoken to stated had allowed them to settle in to the home a lot easier. One room for example had an Irish theme due to the service users family background, which he was able to tell the inspector about and how comfortable he was at the home. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 18 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. The home has a robust system in place for staff recruitment and training, which ensures service users they are being looked after by adequately employed staff. EVIDENCE: The rotas for all departments were seen. The one for kitchen and domestic and administration staff appeared adequate to the needs of those areas. Staff stated they were happy with their hours and the present schedules set for them. Care staff also stated that the amount of hours set on their rota gave them quality time with the service users and those spoken too stated that all their needs were being met and the staff had a very caring and calm attitude when dealing with their needs. Staff were seen throughout the day approaching service users with dignity and respect and assisting them calmly and professionally in a variety of tasks. The home has nearly achieved the 50 target for staff being trained to NVQ level 2. They are using an outside company, but the manager is an assessor and 2 others are in training. Staff stated they feel this has enhanced the delivery of care to service users with the knowledge they have acquired. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 19 5 staff files were tracked and found to have all the necessary information to assure the inspector they had been adequately checked and were safe to work with this category of service user. The training files of a selection of staff were seen and showed good documented evidence of training attended. There was evidence of an induction plan and a variety of statutory and service specific training, which had taken place. The training plan is developed on a six monthly basis and takes into consideration all areas of training for groups of staff and individual staff needs. This enables the staff to have a good knowledge base to meet the needs of service users. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 20 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, 32, 33 and 36. The home has a robust system in place to ensure that the quality of care delivered to service users is provided by supervised staff with a sound knowledge base. EVIDENCE: The manager has completed her Registered manager’s award, which has enhanced her skills to ensure the home is run to an acceptable standard, service users needs are met and staff are safe to work with the people who live there. She also keeps her other training up to date and records this to enable her to maintain a “live” registration with the Nursing and Midwifery Council. The Company has as robust system in place to audit the quality of care given to service users and that visitors and staff have input in to the running of the building as well. This was evidenced to the inspector in a number of ways. For Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 21 example audits are competed on a regular basis by the home manager, other senior personnel in the building and regional and head office staff. These cover areas such as care plans, staff recruitment and training and maintenance checks. The home also holds regular meetings with service users, relatives, staff and surveys visits such as other health professionals and next of kin of service users, to ensure the home is providing the right type of service for each individual. The business plan for the home had been completed in April 2005 for one year and covered strengths, weaknesses, opportunities threats and action to be taken in forth coming year. This shows the home is planning and developing the home as an on going process. A calendar was seen to be in place for supervision of staff and the system explained to the inspector. This ensures that all staff have received supervision on a regular basis and their needs and any concerns addressed, to ensure they are safe to work with the service users. Logs were seen with signatures of the staff member and supervisor. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 2 18 2 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X X Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 23 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 OP9 Regulation 13.2. Requirement Timescale for action 28/02/06 2 OP11 12.1.a. 3 OP17 12.2. 4 OP18 13.6. The registered person must ensure that all alternations to medication records state who authorised the change and that there is better stock control of medication. The registered person must 28/02/06 ensure that all policies relating to the care of the dying person are up to date and follow latest legislation. (Previous time scale of 30/06/05 not met). The registered person must 28/02/06 ensure that all policies relating to the legal and civic rights of service users are in place. (Previous time scale of 30/06/05 not met). The registered person must 28/02/06 ensure that the policies and procedures for the protection of vulnerable adults reflect latest legislation and current guidelines. (Previous time scale of 30/09/04 not met). Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 24 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 OP28 Good Practice Recommendations The manager is aware of the deadline to ensure that 50 of staff have completed their NVQ level 2 awards. Bay Tree Court DS0000002875.V264435.R01.S.doc Version 5.0 Page 25 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.V264435.R01.S.doc Version 5.0 Page 26 - 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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