Inspection on 23/05/06 for Bay View Nursing & Residential Care Home Ltd.

This inspection was carried out on 23rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 View Nursing & Residential... 24/10/05

Bay View Nursing & Residential... 29/06/05

Bay View Nursing & Residential... 05/01/05

Bay View Nursing & Residential... 18/08/04

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Poldhu

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Belma

Hunters Care Centre

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bay View Nursing & Residential Care Home Ltd. 2-6 Bay Road Walton-St-Mary Clevedon North Somerset BS21 7BT Lead Inspector Paul Grey Unannounced Inspection 23rdMay 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 View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bay View Nursing & Residential Care Home Ltd. Address 2-6 Bay Road Walton-St-Mary Clevedon North Somerset BS21 7BT 01275 343109 01275 878003 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) Bay View Nursing & Residential Care Home Ltd. Mrs Margaret Morris Mrs Margaret Morris Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 40 persons aged 65 years and over. Staffing Notice dated 26th May 1999 applies. Manager must be a RN on part 1 or 12 of the NMC register. Date of last inspection 24th October 2005 Brief Description of the Service: Bayview is a large period building registered to care for up to 40 service users. Upper floors and a basement area are served by 2 lifts and the home is flat throughout. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted over a period of 6 1/2 hours in the presence of the homes manager. The inspection was scheduled in part, as a consequence of concerns raised by professionals involved in the care of one service user. The Inspector reviewed this service users notes and care files, spoke with staff members and meeting with the service user. The Inspector noted a good standard of care was delivered to the service user, which was extremely well documented. The inspector found no grounds to uphold the complaint. The inspector notes the service user well has settled at the home but has made a requirement regarding staff training. The Inspector noted an additional program of care, in the form of day care support provided by Brandon trust, is available for this service user. However the service users needs are primarily learning disabilities not general nursing. Given the period of time this service user has lived at Bayview and the location of an elderly relative, the inspector believes it is in the service users interest to remain at the home. The Inspector conducted a tour of the premises, spoke with service users, care staff and ancillary staff, spent time with the homes administrator and manager, reviewed the homes documentation, care planning and service user files in some depth. The Inspector noted a number of service users with learning disabilities. The Inspector makes recommendations later in the report regarding meeting these service users needs. The Inspector found a robust service offering a good standard of care to its service users and commends the entire staff team on a good service. What the service does well: Bayview provides a good standard of nursing care to service users with a range of needs. Care is of a good standard and the home is able to provide clear evidence of its abilities to meet service users needs. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 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. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 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 View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 The outcome for service users was good. Service users are assessed by the service prior to moving in. Service users referred for intermediate care are helped to maximise their independence on return to the community. EVIDENCE: The Inspector spoke with service users, staff members, the manager and reviewed documentation. The Inspector noted comprehensive preadmission assessments were completed. The Inspector noted that these were well documented and appeared to have followed a clear criteria to ensure the home can meet the service users needs. Service users plans of care were based upon clear assessment procedures. The service provides occasional intermediate care. Staff at the home of qualified and appropriately trained to support service users staying for and intermediate visit. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 9 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, 10 The outcome for service users was good. The service users health, personal and social care needs are set out in a plan of care. Service users make decisions about their lives with assistants as needed. Service users, where able are responsible for the own medication and are protected by the homes policies and procedures for dealing with medicines. Service users are treated with respect and the right to privacy is upheld. EVIDENCE: The Inspector audited plans of care. The Inspector noted the home had in depth and comprehensive assessments of service users needs. This was used to draw up the service users plan of care. The Inspector was able to track how an individual assessed the need was met and reviewed. This was good practice. The Inspector noted that service users care plans set out in detail any action that was required on the part of the staff team. The Inspector was able to track these to ascertain whether these actions had been taken. The staff team have involved the service users in drawing up of the plans of care. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 10 Service users are supported to gain access to healthcare services were appropriate, such as the GP dentist optician. The Inspector noted evidence of this in service user assessments and care plans. The home had been very thorough in assessing and meeting these needs. The Inspector noted the staff monitor service users psychological health where possible. One service user with extensive learning disabilities was identified by the Inspector as possibly being beyond the remit of care provided at the home. The Inspector is unsure how the staff, without specialist training are unable to assess this service users psychological health. This is subject to recommendation and requirement later in the report. The home has a policy for the receipt, recording and storage of medication. This is done by the trained nurses on the premises. The Inspector noted that the nurses monitor the service users and call GP or appropriate medical staff if there are any concerns relating to the medication. The Inspector observed the staff team working with service users. The Inspector noted service users were treated with dignity and privacy by the staff team. The Inspector observed the personal hygiene and support was done in a private with due respect for the service users dignity. This same theme emerged in the care notes. The Inspector noted service users were wearing their own clothes and were addressed by their preferred term by the staff. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 11 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, 15 The outcome the service users was good. Service users find life experienced at the home matches their expectations, preferences and social, cultural and religious needs. Service users are supported to maintain contact with friends or family. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome and appealing balanced diet. EVIDENCE: Service users benefit from flexible routines during the day. Service users can get up as they wish, have lunch at the time they prefer and make any religious observances. The home provides a modest range of leisure activities for the service user group. The Inspector noted service users interests are documented. Whilst the home does not provide formal day care activities (this may be obtained from external agencies if appropriate) leisure activities are occur within the home. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 12 Visitors and service users spoken with inform the Inspector that they are encouraged to visit at any reasonable time. Service users are able to have the visitors in private in their own rooms. Service users handle their own finances where at all possible, or a next of kin where appropriate. Failing this, should it be necessary the home will support service users with their finances. Records are stored in accordance to the data protection act. The Inspector noted that service users benefit from a pleasant appealing diet. The Inspector noted a four-week rotating menu was on offer and mealtimes were relaxed and congenial. Special diets can be obtained should they be needed; the home can also provide culturally appropriate diets of the people of different ethnic origins. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 13 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, 18 The outcome the service users was good. Service users are confident their complaints will be listened to and acted upon. Service users are protected from abuse. EVIDENCE: The Inspector noted the home has a simple, clear, and comprehensive complaints procedure. Staff are aware of this and service users all visitors are supported to use it. There is documentary and statement evidence to indicate that any complaints are dealt with within 28 days. The home keeps a record of any complaints. The registered person insures service users are safeguarded from potential abuse. The home has robust procedures for reporting suspicions all evidence of any suspected abuse either to the management or to external agencies. Service users are protected from staff who may be unsuitable to work with vulnerable adults by the homes employment practices. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 14 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, 26 Service users live in a safe, well-maintained environment. The home is pleasant and hygienic. EVIDENCE: The layout of the home is suitable for the purpose of caring for people with nursing needs. The property is accessible and well maintained. The Inspector has made a number of minor requirements regarding routine maintenance. The Inspector noted evidence of a clear and extensive program of maintenance throughout the building. The premises were clean and hygienic throughout. The Inspector noted no evidence of offensive odours throughout the building. The Inspector noted appropriately located hand washing facilities. The home has appropriate sluicing facilities. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 15 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, 30 The outcome for the service users was good. Service users needs are met by sufficient numbers of staff. Service users are in safe hands at all times. Service users are protected by the homes recruitment policy and procedure. Staff are trained and competent to do their jobs. EVIDENCE: Service users are supported by sufficient qualified and unqualified staff at the home. The Inspector reviewed the homes staff rotor, which demonstrated clearly that the home met or exceeded the staffing requirement. The manager informed the Inspector the where necessary additional staff would be rostered to ensure that the service users needs were met. The home employs domestic staff in sufficient numbers to maintain clean and pleasant environment. In excess of 50 of care staff have achieved NVQ level 2 or its equivalent. The home manages a Topps compliant training program. The Inspector audited the homes recruitment files. The Inspector was able to confirm that all employees have obtained 2 references, presented to appropriate forms of ID, and had received POVA and CRB checks prior to starting work at the home. Service users are protected by these processes. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 16 The home has an ongoing staff training and development programme. Staff receive in excess of 3 paid training days per year and statutory training is paid for by the home. All staff receive induction training and the Inspector found appropriate evidence of this in staff records. The Inspector has made a recommendation regarding staff training. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 17 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, 38 The outcome for service users was good. Service users live in a home, which is run by a person who is fit to be in charge. The home is run in the best interests of the service users. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted. EVIDENCE: The registered manager is qualified and competent to run the home. The manager has in excess of the required 2 years experience, is a qualified nurse and experienced nurse manager. The manager is familiar with the conditions diseases of old age. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 18 During inspection the manager showed the Inspector the homes new quality assurance processes. These were comprehensive, in depth and provided an excellent basis for the homes quality assurance processes. The registered manager and staff team were able to demonstrate a commitment to ongoing professional development, (please see the Inspectors recommendation for the staff team regarding working with peoples learning disabilities). The Inspector also noted policies and procedures are reviewed in the light of changing procedures and legislation. This was good practice. Previous requirements by the commission have been implemented by the home in a timely fashion. Staff and service users at the home are protected by safe practices. The staff team receive regular updates for moving and handling. Food hygiene training is provided for staff working within the kitchen. The manager also ensures that appropriate training is available regarding storage of hazardous substances to protect service users and staff. Water at the home is regulated and within the limits of 43°C . The Inspector also noted evidence of clear provision of maintenance on the premises. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 19 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 3 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 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x x x 3 Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 20 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 OP8 Regulation 14 1 a Requirement The Inspector requires that training is provided by an appropriate body to support staff develop a theory and practise base to support meet the needs of service users with learning disabilities. The Inspector requires the following maintenance tasks be undertaken. Room 13, misted double glazing units to be replaced. Carpet to be replaced. Room 2, ceiling to be redecorated in area of previous water damage. Room 4, misted double glazing units to be replaced. Timescale for action 30/09/06 2 OP19 23 2 b 01/03/07 Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 21 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 OP8 Good Practice Recommendations The Inspector recommends the home implement LDAF training to a staff in dealing with service users with learning disabilities. Bay View Nursing & Residential Care Home Ltd. DS0000049283.V293369.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 View Nursing & Residential Care Home Ltd. 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