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Inspection on 29/06/05 for Bay View Nursing & Residential Care Home Ltd.

Also see our care home review for Bay View Nursing & Residential Care Home Ltd. for more information

This inspection was carried out on 29th June 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a safe, structured environment with well trained and caring staff.

What has improved since the last inspection?

The inspector is unable to comment as this was his first inspection of the service.

What the care home could do better:

This was a well organised service delivering a high standard of care. The inspector noted a range of carpets were tired, stained or needed replacing. A balcony at the rear of the property needed to be taken down as it was a health and safety hazard.

CARE HOMES FOR OLDER PEOPLE Bay View Nursing & Residential Care Home Ltd 2-6 Bay Road Walton-St-Mary Clevedon BS21 7BT Lead Inspector Paul Grey Announced 29 June 2005 th 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. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 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 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) 01275 343109 01275 878003 Bay View Nursing & Residential Care Home Ltd Mrs Margaret Morris Care home with nursing 40 Category(ies) of Old age (40) registration, with number of places Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 40 persons aged 6 years and over. Staffing Notice dated 26th Ma 1999 applies. Manager must be a RN on part 1 or 12 of the NMC register. Date of last inspection 5th January 2005 Brief Description of the Service: Bayview is a large period building rigistered to care for up to 40 service users. Upper floors and a basement areaare served by 2 lifts nand the home is flat throughout. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector found a pleasant, well run home with content, well cared for service users. The homes administration and general infrastructure support a well trained and caring team of nurses and carers. The inspector commends the team and the manager on the overall standard of care within the home. Toward the end of the inspection process a fire broke out caused by an electrical fault. All fire protective measures and evacuation procedures worked well as did the team during this period of duress. The inspector commends the manager and team for their professional and well organised evacuation of service users. What the service does well: What has improved since the last inspection? What they could do better: This was a well organised service delivering a high standard of care. The inspector noted a range of carpets were tired, stained or needed replacing. A balcony at the rear of the property needed to be taken down as it was a health and safety hazard. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 Page 6 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 D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 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 standard(s) 1,3, 5 The home has a comprehensive statement of purpose and service user guide to support service users considering the service. The inspector noted the home provides an extensive assessment of new service users needs to ensure the home could meet them. Potential service users are invited to visit the home prior to moving in. EVIDENCE: The inspector noted the homes statement of purpose and service user guide met national minimum standards. The inspector audited 4 assessments, all were comprehensive and in depth. The inspector case tracked care and noted assessed needs were appropriately care planned. The manager informed the inspector that service users are invited for a trial visit prior to a trial period at the home. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 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 standard(s) 7,9,10 The service users plan of care meets national minimum standards. The home has appropriate policies and procedures to safely administer medication to service users. The inspector observed services users dignity was respected at all times. EVIDENCE: The inspector audited 4 plans of care. All set out service users needs and outlined how the home would meet them. The inspector noted that the plans of care were very much based around physical needs with little reference to holistic care and addressing issues such as emotional needs. In addition the care plans were very prescriptive with little evidence of involvement of the service user. However the inspector noted that physical and nursing needs were very well documented and easily audited against risk assessments and staff interaction. Whilst not person centred the plans of care outline a good standard of nursing care within the home. The inspector noted policies for the administration and storage of medication. Staff spoken with were to outline to the inspector how medication should be stored and policies for administration. The inspector staff knock on all doors prior to entry, all service users are addressed with dignity by their preferred name and that staff respect service users dignity. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 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) 12,13 The day to day running of the home meets service users expectations. Service users are encouraged to maintain contact with friends and family. EVIDENCE: Service users informed the inspector they approved of the overall program of day to day activities and felt the life at the home was as they expected during the admission process. The inspector was given positive feedback from relatives via questionnaire prior to inspection. Family spoken with informed the inspector that visiting hours were open within reasonable times. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 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) 16,18 The home has a clear and effective complaints procedure. The home’s policies and procedures protect service users from abuse. EVIDENCE: The home has a procedure for handling complaints and the inspectors noted that this was followed for a complaint made. The complaint concerned staff communication and was partly substantiated and acted upon. The homes procedures for protecting service users from abuse were clear and comprehensive. Staff spoken with clearly understood their own role should abuse be observed. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 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) 19,24,26 The home is an extensive period property that is generally well maintained. However the home failed to meet national minimum standards over one health and safety issue and a minor issue concerning carpets. EVIDENCE: The home was generally well maintained and pleasant. However, to the rear of the property was a balcony off a service users bedroom with extensive evidence of deterioration. Sections of the floor had collapsed and a number of floor tiles were hanging precariously over the edge. The balcony appeared a major health and safety risk. The home had taken reasonable safety precautions and the balcony was not accessible to service users. The garden area overhung by the balcony was restricted to access to staff only but in the inspectors opinion still constituted a significant risk. This was subject to requirement Carpets in the communal area of the first floor were soiled and in places presented an uneven walking surface. This was also subject to requirement. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 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) 29, The home operates a thorough recruitment procedure. EVIDENCE: The inspector audited 4 staff files. All contained appropriate references, 2 forms of ID and confirmation of CRB and POVA checks. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 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) 31,32, and 37 The manager of the home is fit to do so and competent to run the home. The manager indicated a clear direction and overall ethos of care which the team follow. The manager ensure records are stored securely. EVIDENCE: The manager has vast experience in both nursing and management; she is an RGN and an NVQ assessor. There was plenty of evidence during the inspection that demonstrated that the manager provided clear leadership in the home. Staff and service users all felt the manager was clear on her objectives and approachable. Records are maintained, up to date and securely stored. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 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 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION x x x x x 1 x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 2 x x x x 3 x Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 Page 16 no 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 24 Regulation 23 (2) Requirement The inspector requires the rear balcony as identified to the manager is made safe or removed from the premises. The inspector furthermore requires a written outline of what action is taken over this matter. The inspector requires the blue carpet in the communal areas on the first floor be replaced Timescale for action 30.8.05 2. 24 23 (2) 31.12.05 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 24 Good Practice Recommendations The inspector reccomends a schedule of carpet cleaning as some carpets were stained or discoloured. These may be subject to requirement on subsequent inspections if carpet cleaning is unsuccessful. Bay View Nursing & Residential Care Home Ltd D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier 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 D53-D02 S49283 Bay View V227556 290605 Stage 4.doc Version 1.30 Page 18 - 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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