CARE HOMES FOR OLDER PEOPLE
Bay Tree The Station Road Robin Hoods Bay North Yorkshire YO22 4RL Lead Inspector
Pauline O`Rourke Unannounced Inspection 17th 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 The DS0000007738.V260189.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 The DS0000007738.V260189.R01.S.doc Version 5.0 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.V260189.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th May 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. Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection including preparation time took place over 8 hours. A tour of the building was conducted. A number of the service users records, staff records and records about the management of the home were inspected. 7 of the service users, and 3 staff on duty were spoken with. What the service does well: 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. Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 6 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.V260189.R01.S.doc Version 5.0 Page 7 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 Prospective service users are given detailed information about the home prior to their admission. EVIDENCE: The Statement of Purpose was reviewed at this inspection and was found to include details about the home as required by the Care Homes Regulations 2001. Several service users spoken with had seen a Statement of Purpose prior to their admission and a copy is kept in the bedrooms. Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 8 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, 9 and 10 The health, social care and personal needs of the service users are met. EVIDENCE: The care plans now identify what assistance each service user requires throughout the day. Staff spoken with continued to be knowledgeable about the support required by the service users. There is a medication policy in place and staff that handle the medication have received training. The storage and administration of the medication was seen to be appropriate and records kept were accurate and up to date. Service users spoken with said that they could manage their own medication if they wanted to but they were happy for the manager to look after it for them. Throughout the inspection the staff were observed treating the service users with respect at all times. The staff said that ensuring the service users are treated with respect is included in their induction and foundation training. Service users spoken with said that the staff were always polite, friendly and respectful.
Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14. The service users are able to keep their own routine within the home and join in with social activities if they wish. Service users are encouraged to maintain contact with family and friends. EVIDENCE: Records inspected, comments made by service users and observations made during the inspection all identified that routines within the home were relaxed and geared to meet the needs and wishes of the service users where at all possible. Activities also take place on a daily basis and this can be a sing-a-long, talking with the service users, reminiscing or interacting with the visitors. The service users spoken with enjoyed their own company and did not always want to take part in organised activities. The service users said that their visitors are always welcome and are offered refreshments during their visit. A visitors’ policy is in place and all visitors sign a visitor’s book on entering the home. Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 10 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Service users were confident that any complaints or concerns they had could be raised and acted upon. Service users are protected from possible abuse through staff training. EVIDENCE: The complaints policy now includes the information as required by the Care Homes Regulations 2001. Service users spoken with knew that if they had any concerns they could discuss them with the managers or any of the staff. There have been no complaints received by the Commission for Social Care Inspection in the last 12 months. There is an Adult Protection Policy in place. Staff spoken with had received training in Adult Protection issues and they had a good understanding of their responsibilities if they believed any inappropriate behaviour was taking place. Policies are also in place regarding the management of service users money. Staff are also subject to a criminal records bureau disclosure and a protection of vulnerable adults check to ensure that they are suitable to work in a care setting. Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: None of these standards were assessed at this inspection. Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 12 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): 28 and 29. The service users needs are met by staff that have been through a thorough recruitment procedure before their employment. EVIDENCE: The staff team at The Bay Tree are experienced carers and the manager is in the process of organising training for them through The Wilf Ward family rust and Yorkshire Coast College. He is also exploring the option of distance learning courses available through local universities. Staff spoken with said they wanted to do training that would help them in their work and those who had completed training said that they enjoyed it. Staff records seen contained all the documentation as required by the Care Homes Regulations 2001.and there was evidence to show that all new staff had a POVAFIRST check prior to the commencement of their employment, a full Criminal Records Bureau disclosure was also available. Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 13 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35. The home is appropriately managed, however, there is no quality assurance of the service provided. EVIDENCE: The proprietor also manages the home, he does not have a recognised qualification and is not looking to undertake such a qualification. He and his wife have been running the home for over 10 years and whilst there are areas identified as requiring improvement the service users have not been placed at any risk due to the lack of a qualification. The manager is currently in the process of identifying a quality assurance system suitable for his business. The home does not handle service users personal allowance. Families are encouraged to handle finances where service users cannot.
Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 14 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 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X X Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 15 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 OP33 Regulation 24(1) Requirement The registered person must establish and maintain a system for reviewing the quality of the care provided at the care home.(previous timescale of 30.06.05 not met) Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bay Tree The DS0000007738.V260189.R01.S.doc Version 5.0 Page 16 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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