Inspection on 01/11/06 for Bay Tree The

This inspection was carried out on 1st November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bay Tree The 01/12/08

Bay Tree The 25/10/07

Bay Tree The 17/11/05

Bay Tree The 05/05/05

Bay Tree The 24/02/05

Bay Tree The 27/09/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

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 The Station Road Robin Hoods Bay North Yorkshire YO22 4RL Lead Inspector Karen Ritson Key Unannounced Inspection 31st October & 1st November 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 The DS0000007738.V318100.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 The DS0000007738.V318100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bay Tree The Address Station Road Robin Hoods Bay North Yorkshire YO22 4RL 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) 01947 880718 Mr Thomas Edward Dobson Mrs Jean Dobson Mr Thomas Edward Dobson Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 2005 Brief Description of the Service: The Bay Tree is a detached Victorian building set in its own ground in village of Robin Hoods Bay. There are three floors, with the residents occupying the first two floors and the proprietors the top floor. A shaft lift provides access to the first floor but due to the lay out of the building several bedrooms and one bathroom have restricted access due to there being two or three stairs. The Bay Tree is located close to all the village amenities although access to public transport is limited because of the location. The front garden is well maintained and is enclosed. Seating is provided for use by the residents if they want to. At the rear of the building there is a veranda for use by the residents. The home has a statement of purpose and service user guide, which provide information about the scope and nature of the care and facilities on offer. These, with CSCI reports, are available on request at the home. The fee charged is usually £345 per week; however, this may vary with the degree of assessed needs. Chiropody, hairdressing and newspapers are not included in this fee and these are charged at cost. This information was provided to CSCI on 07/08/06. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection for this service took 12 hours. This includes time spent gathering information and examining documentation before and after a site visit and in writing the report. The site visit took place on 1st November 2006 between 9.30am and 3.30pm. Information for this inspection was gathered from the following: • A tour of the premises • Observations of care throughout the day of the site visit. • Speaking with service users. • Case tracking three service users on the day of the site visit. • Consulting health care professionals and relatives. • Looking at information provided by the manager in a pre inspection questionnaire. • Notifications sent to the commission from the home since the last inspection. • Examining policies, procedures and records kept at the home. All key standards were looked at during this inspection. The manager was present throughout the day of the site visit. What the service does well: This home offers a good level of care for service users, within a homely and well -decorated environment. The manager and staff get to know the service users well and have a detailed knowledge of what each person needs; they also have the time to give this care in an unhurried way. This results in good, appropriate care for each individual. A care manager wrote: ‘I have always found the standard of care very high. The home always looks well cared for and the residents appear to be settled and happy.’ The meals are appetising and there is a good choice on offer. Service users feel able to complain if there are any concerns and they are confident any comments will be acted on. Staff are supported in their jobs and can go to the manager if there are any concerns. Health and safety is protected by policies and procedures. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 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 The DS0000007738.V318100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. Quality in this outcome area is good. Prospective residents and their representatives have the information needed to choose a home. Service users needs are assessed and a care plan is drawn up from this. This ensures their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users receive a thorough assessment of care needs before admission. This includes risk assessments where relevant. The home completes a personal history for each service user, and a description of each person’s likes, dislikes and interests is included. One said: ‘They knew what I needed from the start.’ Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 9 Observations of care showed that service users needs were well known to all staff. The manager and staff said service users and their relatives are encouraged to look around the home before admission and the home provides a statement of purpose and service user guide to help people make a decision. The home does not usually offer intermediate care. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. The health and personal care a resident receives is based on individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are detailed and often reviewed. Risk assessments are included when necessary. All visits from health care professionals are recorded separately which makes is easy to track the health care of each individual. The home is good at monitoring the day to day health of each service user. Weight is recorded; continence and any pressure areas are monitored. One service user said: ‘They know what I need and they’re very good, when you ask for things they don’t mind, they’re very kind.’ Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 11 A GP commented that his patient was well cared for at the home and although the care needs of this person were complex, the staff had managed the plan well. He said: ‘I have been very impressed with how they have coped.’ A health care professional had written: ‘Residents are treated with respect.’ Medication is kept, given and recorded appropriately, with policies in place. Staff who handle medication have had training. None of the service users handle their own medication. Observations of care showed that service users are treated kindly with their privacy and dignity respected. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. Service users are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Service users receive a healthy, varied diet, which they enjoy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said they preferred to live quietly and were not particularly interested in going on trips. Some said they went to church when they felt well enough. The manager organises a music afternoon, with a visiting entertainer from time to time, particularly around Christmas and there are games, jigsaws, books and TV available. Service users sometimes go out for accompanied walks when the weather allows. The home employs an activities organiser although the post is vacant at present. Staff were observed sitting with service users and having conversations with them throughout the day. Service users said they could have visitors at any reasonable time and were satisfied with the level of entertainment offered to them. Most service users had visiting relatives and friends who would take them out on a regular basis. Menus were submitted which showed a good choice of meals. All service users said they enjoyed the meals. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 13 One said: ‘They’re always first class.’ Another said: ‘They asked me what I liked to eat when I came here and they often put my favourites on the menu.’ A health care professional wrote: ‘The food is of a high standard.’ A midday meal was observed. There was a quiet but friendly atmosphere and those service users who required it, were assisted kindly and without rushing. One service user is offered a diabetic diet. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents have access to an effective complaints procedure; their complaints are listened to and acted on. Service users are protected from abuse, though updated staff training and abuse procedures would improve this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and procedure. Service users said they could speak with staff if there was a problem or they had a complaint and that they were confident they would be listened to and any concerns acted upon. Some staff have received abuse awareness training through their NVQ qualification. Not all staff have received abuse awareness training beyond their induction training however and service user protection would be improved by ensuring this takes place. The home has an equal opportunities policy and procedure. Service users said they felt well cared for in the home, none said they had ever had cause to complain or had ever felt unsafe. One said: ‘All the staff are kind, and would listen to us if there was a problem.’ A health care professional said: ‘Any advice is immediately acted upon.’ This responsive approach ensures that service users are protected. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. Service users live in a safe, well-maintained and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well decorated and homely. Service user rooms are decorated to their taste. One service user said: ‘I am very satisfied with my room, I have everything I need and a lovely view.’ Many rooms were personalised with pictures, photographs and items of service users own furniture. Heating may be altered in each room. The recommendations of the latest fire authority visit are being implemented. Fire doors are now held open with magnetic catches and unauthorised means have ceased, new emergency escape signs are to be fitted. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 16 The home is also in the process of devising a new fire risk assessment for the building. The laundry is situated away from the kitchen and meets the standard. Service users said they had no problems with their laundry. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. Staff in the home are trained and in sufficient numbers to fulfil the aims of the home and meet the changing needs of residents. Staff recruitment needs attention. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four staff files were examined. Some staff had been recruited with CRB checks from previous employment. The manager stated that he was in the process of verifying the validity of these CRB checks but this was proving to be a lengthy process. Meanwhile, these staff were working at the home and had not received a POVA first check. This places service users at potential risk. All new staff receive induction and foundation training with certificates on file. Sufficient staff are on duty to allow service users to receive one to one attention when needed. Staff were observed speaking with service users and offering care in a kind and thoughtful way; they were approachable, and obviously understood each service users care needs well. Staff said they received good support from the home’s management and they felt this helped them to provide good care in an unhurried way. One commented: ‘If I’ve got any questions I just go and ask.’ Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 18 One service user said: ‘The staff are lovely and they always have time.’ Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. Service users benefit from an open style of management based on respect and from the considerable experience of the managers. Service user views inform practice to an extent though this would better if a business plan were developed. Service users welfare is protected by good health and safety systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The proprietor/manager has many years of experience in managing the home. Staff said they received good support from the home’s management and they felt this helped them to provide good care in an unhurried way. The home has an annual quality monitoring system, where the views of service users are canvassed. This is in the process of being developed and the Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 20 manager said he was devising a way in which these formally gathered views could be used to inform future practice, and be incorporated into an annual plan. The home does not handle service users finances. Health and safety is protected and promoted through staff training, effective risk assessments, regular checks on water temperatures, the checking and maintenance of electrical systems, gas supply, and servicing of all equipment. An updated fire risk assessment is being drawn up. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 21 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X N/A X X 3 Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 18. Requirement All staff must have an updated CRB check prior to commencing service. A POVA first check may be carried out but staff must be supervised pending results of the CRB. Timescale for action 01/11/06 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 2 Refer to Standard OP33 OP18 Good Practice Recommendations THE quality assurance system should include an annual plan to implement suggested improvements. This should be made available to the public. All staff should have abuse awareness training to a level which ensures they are aware of potentially abusive situations and practices and that they are aware of the procedure to follow should abuse be suspected. Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bay Tree The DS0000007738.V318100.R01.S.doc Version 5.2 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!