Inspection on 05/05/05 for Bay Tree The

This inspection was carried out on 5th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 The 01/12/08

Bay Tree The 25/10/07

Bay Tree The 01/11/06

Bay Tree The 17/11/05

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 The Bay Tree Station Road Robin Hoods Bay North Yorkshire YO22 4RL Lead Inspector Pauline ORourke Unannounced 5 May 2005 09:30 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 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. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Bay Tree Address Station Road Robin Hoods Bay North Yorkshire YO22 4RL 01947 880718 N/A N/A Mr Thomas Edward Dobson and Mrs Jean Dobson Mr Thomas Edward Dobson Care Home 18 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 24/02/05. 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 Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over 16 hours. A tour of the building was conducted. A number of the residents records, staff records and records about the management of the home were inspected. Five of the fourteen residents, four of the six staff on duty, a district nurse and a GP 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. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 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 standard(s) 1,3 and 4. Prospective residents are not provided with information that allows them to make an informed choice about The Bay Tree. EVIDENCE: A description of the physical environment has not been included in the Statement of Purpose. This is an outstanding requirement from the two previous reports. Assessments seen were basic but the information provided made the care staff aware of the assistance each service user required. Discussion with a district nurse and a local GP highlighted that the home works closely with them to ensure any admissions made are appropriate. This working relationship coupled with the assessment information provided by a care manager or the registered managers’ own assessment allows the home to make an informed decision as to whether they can meet the needs of anyone admitted to the home. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 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 standard(s) 7 and 8 The health and personal care needs of the residents are met without them being identified in a care plan. EVIDENCE: The resident files seen contained basic assessment information, monthly reviews, 6 monthly reviews, a moving and handling plan and contact sheets. A care plan, outlining the specific assistance required by an individual was not seen during the inspection. Discussions with the registered manager and staff demonstrated that they had a good understanding of the needs of individual residents. A care plan would inform new and existing staff of the level of assistance required by an individual resident. The monthly reviews would then reflect any changes needed in the care plan. Residents spoken with were not aware that they had a care plan or that there was a review of their general health and change in needs every month. The resident’s files did contain evidence that their health needs are met. The residents confirmed that they saw the doctor on request. The district nurse spoken with said that she provides support and assessments for continence The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 9 issues and situations where residents require pressure relieving equipment. The doctor confirmed that home only calls him out when necessary and that there is always someone to discuss needs of the resident when he calls. The registered manager confirmed that other health services are obtained when required, including the services of a visiting optician and chiropodist. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 10 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 standard(s) 15 The meals are nutritious and balanced and offer a healthy and varied diet for the residents. EVIDENCE: The menus are planned on a four-week basis and they offered varied and balanced diet. The cook said that they use local fresh produce. The residents all said the food was nice and the meal served at lunchtime was well presented and hot. There was minimal waste at the end of the meal. The cook provides meals for a diet controlled diabetic and adjusts the main choice to ensure they have something similar without loosing the variety and choice. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 11 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 standard(s) 16 Residents were confident that any complaints or concerns could be raised and would be dealt with. EVIDENCE: A master copy of a complaints policy was seen in the office. This information was not available around the building either in the form of a notice or in the Statement of Purpose and Service User’s Guide. A basic complaints schedule was available but this did not give any time scales in which complaints would be dealt with. This is an outstanding requirement from the last two inspections. When asked about this Mr Dobson said that he wasn’t expecting an inspection for another 3 or 4 months and so had not tackled any of the requirements. Residents spoken with did say that if they had any concerns then they would take them to Mr Dobson. A visitor spoken with was not aware of the complaints policy but said that she did not expect to know of it unless she wanted to complain. There have been no complaints received in the last twelve months. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 12 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 standard(s) 19,22 and 26 The residents cannot access all areas of the home, but it was clean and maintenance work is carried out when necessary. EVIDENCE: The home is situated in the seaside village of Robin Hood’s Bay and is a detached property set in its own grounds. The gardens are accessible to the residents and benches have been provided in the front garden. To the rear of the building there is a veranda for use by the residents. The resident accommodation is set out over two floors and access to several areas in the home is limited as there is stepped access. The areas of the home seen were warm, clean and odour free. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 The residents have not been protected from possible abuse as the procedures for the recruitment of staff have not been followed correctly. EVIDENCE: The staffing levels are adequate to meet the needs of the residents. The staff records seen contained a staff contact sheet, position, experience, the date they commenced work and a record of training. There was no evidence an application form had been completed. A criminal records bureau disclosure nor references had been obtained. Staff receive the basic statutory training but there was no evidence that induction or foundation training to TOPSS standards had been undertaken. There was no evidence that staff receive any further training relating to the ageing process to give them a greater understanding of the residents. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 38 The health and safety of the residents is promoted, however, there is no quality assurance of the service provided. EVIDENCE: There is no programme in place to gather the views of the residents, their relatives and visiting professionals. This means that the manager cannot review the service provided at the Bay Tree, or identify areas in which improvements can be made. The staff spoken with confirmed that they had received training in manual handling, first aid, fire safety, food hygiene and COSHH. Evidence to support this was available in the staff files. The equipment used in the home is serviced at the prescribed intervals and health and safety notices were displayed around the building. Accidents are recorded but the registered manager must stop using the A4 book to record the accidents. Accidents must be recorded in such a way I which an individual residents details remain confidential. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 2 x x x 3 STAFFING Standard No Score 27 3 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x x x x 1 x x x x 2 The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 16 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4(1)(b) Requirement The registered person must include detailed information in the Statement of Purpose about the environment when it does not meet the national minimum standard.(Previous timescale of 31.03.05 not met and this has been outstanding for 12 months.) The registered person must prepare a written plan that sets out how a residents needs in respect of their health and welfare are to be met The registered person must provide a complaints procedure that includes a timescale for response to a complaint to all residents (Previous timescale of 31.03.05 not met.) The registered person must ensure that all prospective members of staff comlete and application form, that a criminal record bureau disclosure is obtained and two written references are provided prior to their deployment in the home (Previous timescale of 24.02.05 not met). The registerd person must Timescale for action 30.06.05 2. 7 15 30.06.05 3. 16 22(1) 30.06.05 4. 29 19 With effect from the date of the next appointed member of staff. 5. 30 18(1)c 30.06.05 Page 17 The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 6. 33 24(1) provide a plan to the Commission to show how they intend to ensure that all staff receive training appropriate to the work they are doing. The registered person must establish and maintain a system for reviewing the quality of the care provided at the care home. 30.06.05 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 38 Good Practice Recommendations The registered person should ensure that accidents are recorded in an apropriate manner. The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 18 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 © 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 The Bay Tree J53 J04 S7738 The Bay Tree V223077 050505 stage 4.doc Version 1.30 Page 19 - 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. 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