Inspection on 11/07/05 for Baytree House

This inspection was carried out on 11th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Baytree House 18/02/09

Baytree House 05/03/08

Baytree House 04/12/06

Baytree House 03/01/06

Baytree House 25/01/05

Baytree House 05/08/04

Baytree House 24/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Baytree House Torbay Council 22 Croft Road Torquay TQ2 5UE Lead Inspector Sam Sly Announced 11 July 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Baytree House Address Torbay Council, 22 Croft Road, Torquay, Devon, TQ2 5UE 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) 01803 211300 01803 380164 Torbay Council Mrs Nina Down Care Home 10 Category(ies) of Learning disability (10)Includes Service Users registration, with number aged 16 & 17 years, and Service Users with a of places Learning Disability who may have additional Physical &/or Sensory impairment. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users with Learning Disability who may have additional Physical Disability and/or Sensory Impairment. 2. Service Users aged 16 or 17 years may also be admitted. Date of last inspection 25th January 2005 Brief Description of the Service: Baytree House is owned by Torbay Council and offers short term breaks and a longer term assessment service for adults and younger people aged between 16 and 18 years old with learning disabilities. Some residents may also have additional physical or sensory impairment. Three beds are allocated for the assessment service, two of which are in an annexe with additional kitchen facilities. All the other bedrooms are in the main part of the house. There is also a large dining room, lounge, activity room, and ample bathrooms, showers and toilets. There are bathroom facilities adapted for disabled residents, and wheelchair access throughout the house, to all but three bedrooms. A lift gives access to the first floor. Baytree House is situated in Torquay town centre within walking distance of the shops, amenities, beaches and attractions. There is also access to train and bus routes nearby. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was announced and took place between 2pm and 6.30pm on a weekday in June. It included a tour of the building, examination of care records, staff files, and health and safety records as well as discussion with staff on duty and all the residents at Baytree House at the time. A meal was also shared with the residents. The registered manager, Nina Down, was present throughout the visit and further information was obtained from comment cards that had been received by the Commission. What the service does well: What has improved since the last inspection? What they could do better: Residents assessment, risk assessment and care planning was not comprehensive and does not enable staff to clearly identify and meet residents needs, goals and aspirations. Regular flooding in one part of Baytree is of major concern as it is potentially hazardous and inconvenient for residents. There is a need for a recorded plan, with timescales, to rectifying this problem and ensure regular maintenance projects are carried out. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 6 The registered provider are not carrying out regular monthly visits, so they, and the Commission, cannot be fully aware of what is happening in the home. 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. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 4 The introduction process enables residents to make choices about using Baytree, and makes them feel at home when they arrive, however the assessment process does not ensure staff understand their needs and aspirations. EVIDENCE: There was a clear comprehensive assessment format available at Baytree and a good introductory procedure, which involved a number of visits for tea to familiarise residents and allow them to get to know staff. One resident was spending their first night at Baytree House during the visit, and said he had been to visit several times before and now felt comfortable about staying the night. With regard to this new resident, information, but no assessment and care plan, had been obtained from the placing Local Authority. Staff had carried out an assessment, however neither this nor the Local Authority information was detailed or comprehensive and a clear picture of the resident’s needs and aspirations was not evident. Another resident had been admitted in an emergency a week before and she was well known to staff, a new assessment and plan had not been formulated but was not in their file. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Residents participated in all aspects of life at Baytree, but could not be sure that all their needs and personal goals were reflected in their plans or met be staff. EVIDENCE: It was clear on speaking to staff that they knew residents well, however care plans for three of the current residents were examined and found to vary in quality and detail. Plans had been reviewed, but due to the recording format used, information was not clear. Although the registered manager said residents and family were involved in drafting plans this was not always evident. Some plans included goals others did not. The most recently admitted resident did not have a comprehensive care plan nor did the person admitted in an emergency. The format used for some daily recording meant resident’s personal information was not separated from other residents, so could not be extracted if necessary. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 10 Residents were encouraged to make decisions throughout their stay at Baytree, and this was evident in records, interaction with staff and in the excellent quality assurance system the registered manager had implemented. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 16 and 17 Residents enjoy a range of activities in the home, and as part of the community. Meals are tasty, enjoyable and nutritious. EVIDENCE: Many of residents at Baytree were having short breaks from living at home, so their day activities continued during the stay. Those on assessment had a structured day, which often included day services provided elsewhere. Residents spoken to said there was lots to do at Baytree both in and out of the home. Residents went into the town, or visited the local beaches and local attractions, they also liked going to the pub and social evenings. There were also activities in the home like TV, videos and computer games, art and craft, use of the garden for games, and cooking in the kitchen. Both residents staying at Baytree for assessment had been on holidays this year. One parent had stated on a comment card that more staff were required for activities. The registered Manager was already aware of this concern through the quality assurance system and had increased staffing levels. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 12 Staff said sometimes after a day at work residents just wanted a quiet evening during the week, however at weekends there was always activities planned. The Home’s improvement plan stated that weekly activity plans would be made with residents at each stay so they were aware of what they were going to do. Meals were prepared following a set menu, however there was choice available. A cook was employed, but was not working on the day of Inspection instead one of the care workers who had previously been a chef had stepped in. The meal was tasty, and nutritious and all residents said they enjoyed it. Staff sat with residents during the meal and there was lots of chatting and laughter. Residents special dietary needs were documented and understood. Residents were encouraged to make their own drinks throughout the day. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 20 Residents receive the personal support they require and medication is administered safely. EVIDENCE: Staff received training and were observed to provide sensitive personal support to residents. Residents were encouraged to do as much for themselves as possible. The Registered Manager said there was a good relationship with the local learning disability team, and records and activity during the Inspection showed support was requested when necessary. Medication was being administered and recorded appropriately by trained staff, with those residents able to administering their own medication. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Concerns and complaints were taken seriously and dealt with under a clear complaints policy. Not all staff were fully competent in adult protection procedures. EVIDENCE: There was a clear complaints procedure that was understandable to residents. The registered manager addressed concerns appropriately, and she and some staff had received training on how to handle complaints. Neither the Commission nor Baytree House had received any formal complaints since the last Inspection. Residents said they felt able to approach staff with any worries or concerns, however no one had any concerns when asked. There was a range of adult and child protection policies and some staff interviewed were clear on the procedure for reporting abuse, however a newer member of staff was not clear and records showed that less than half of the staff had received formal adult protection training, so the Commission recommended this. The registered manager is trained to provide this training and to investigate abusive incidents. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 Parts of the building cannot be used at times due to flooding; this is both potentially hazardous and inconvenient for residents. For the rest of the time Baytree has the space and facilities to suit residents and is kept clean, safe and comfortable. EVIDENCE: The registered manager and staff work hard to maintain the environment at Baytree, and on the day of Inspection it was clean and decorated to a comfortable standard. However, a major concern was the regular flooding that occurs in the assessment part of the home which makes it unusable sometimes, and leaves an offensive odour at all times. The registered manager said the Torbay Council were aware of the problem and were working to resolve it however no timescale was available. Maintenance and redecoration was taking place regularly, however there was no clear plan with timescales. The Environmental Health Department had visited since the last Inspection and made some recommendations, one was that fridge temperatures were Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 16 regularly recorded, however this was not happening. The registered manager had raised this recently with the cook. The Fire Service had visited recently and made no requirements or recommendations. The garden was in the process of being made accessible to residents with mobility problems, and was being landscaped as a project by a local day service. There were sufficient systems and procedures in place to control the spread of infection and the laundry facilities were appropriate to meet the needs of residents. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 The staff team were sufficiently checked, trained, experienced and supported to maintain the care and safety of residents. EVIDENCE: There was sufficient staff employed to work with residents, including 1:1 staffing for some people. Agency staff were employed when necessary and sufficient information was available to ensure consistency. The registered manager was in the process of recruiting bank staff for future use. Regular staff meetings take place and staff spoken to said they felt supported and able to approach the management team with concerns. Training for staff included induction and foundation training, fire awareness, infection control, moving and handling, health and safety, disability awareness, bereavement, first aid, epilepsy, handling violence and aggression, adult protection, child protection, deaf awareness, food hygiene, anti-discrimination, and total communication. Three staff files were examined and found to include checks and records to ensure staff were fit to work with residents. It was recommended that the registered providers ensure the Criminal Record Bureau checks carried out cover working with children as Baytree House cares for 16 and 17 year olds. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 18 Records showed, and staff confirmed, they received regular supervision and performance reviews. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Residents and other people involved with Baytree can be confident that their views are paramount to developments at the Home. The health and welfare of residents are promoted and protected. EVIDENCE: All the required safe working training is provided to staff including food hygiene, first aid, and moving and handling. Health and safety checks on gas, electrics, water and risk assessments of the environment and hazardous substances were all up to date, as were the fire checks and the accident book. The registered manager should be commended on the quality assurance system that is in place, which is resident-centred and fully involves their families and other stakeholders. The process for gathering views had been made fun and user-friendly by holding meetings in interesting places like the zoo. An improvement plan for 2005/2006 based on the outcome of the consultation was about to be published and sent to residents in formats they would understand. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 20 Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Baytree House Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x 4 x x 3 x D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 22 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 2 Regulation 14 Requirement A comprehensive assessment must be carried out with the resident before admission. The placing Local Authority assessment and plan must be obtained before a resident is admitted. . A comprehensive care plan must be completed with each resident, and changes must be clearly recorded. Action must be taken to prevent the regular flooding that occurs in the assessment flat (Previous requirement - timescale of 31st May 2005 not met) A maintance and renewal plan recording timescales for completion of short and long term work must be kept (including the flood prevention), and in this instance a copy sent to CSCI. Regular monthly provider visits to the home must take place with copies of outcomes sent to CSCI. Timescale for action 18th September 2005 2. 6 15 18th September 2005 3. 4. 24 23 18th December 2005 18th September 2005 5. 24 23 6. 43 26 18th August 2005 Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 23 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. 3. 4. 5. Refer to Standard 6 23 24 32 Good Practice Recommendations Records, including daily recording, must be separate for each resident. All staff should have attended training on Adult Protection. Fridge temperatures should be regularly recorded. 50 of care staff should have at least NVQ 2 by 2005. Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Baytree House D54-D07 S37128 Baytree House V224271 110705 Stage 4.doc Version 1.30 Page 25 - 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. 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