Inspection on 14/06/05 for Baytree House

This inspection was carried out on 14th 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.

Other inspections for this house

Baytree House 27/02/07

Baytree House 31/01/06

Baytree House 17/01/05

Baytree House 14/12/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE BAYTREE HOUSE 423 Unthank Road Norwich Norfolk NR4 7QB Lead Inspector Kim Patience Announced 14 June 2005 9:30 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. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Baytree House Address 423 Unthank Road, Norwich, Norfolk, NR4 7QB 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) 01603 458503 01603 503528 Mr Thomas Paul Hanley and Mrs Sandra Hanley Mrs Sandra Hanley Care Home 16 Category(ies) of OP Old age registration, with number of places BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17 January 2005 Brief Description of the Service: Baytree House is a care home providing personal care and accommodation for up to 16 older people with one terminally ill bed/service user.Baytree House is a detached Edwardian property situated in its own grounds in the city of Norwich. Bedrooms are on the ground and first floors and consist of sixteen single bedrooms, seven of which have en suite facilities. The home has three communal areas for the use of service users and a passenger lift to assist service users from ground to first floor.Car parking to the front and well maintained gardens to the rear of the premises. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was planned and took approximately 6hrs to complete. On the day of the inspection, a tour of the building was carried out and records relating to staff and service users were inspected. Three service users and three members of staff were formally interviewed and others were spoken to in passing. Service user and relative comment cards were distributed and all 26 were returned, information from these cards has been incorporated in the report. The proprietor/manager was available throughout the inspection for consultation and was helpful in facilitating the process. What the service does well: What has improved since the last inspection? What they could do better: Recruitment procedures and staff files need to be further improved to contain evidence that practice is in accordance with the regulations. The results of the quality assurance audit need to be publicised in a report. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 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. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 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 BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 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) 1,2,3,4,5 Prospective service users are given information about the service that enables them to make an informed decision as to whether the home can meet their needs. Service users are provided with a contract and statement of terms and conditions when entering the home. The home is able to demonstrate its capacity to meet individual needs. Service users have their needs assessed prior to moving into the home. Relatives and friends are able to visit the home to assess the quality and suitability of the service. EVIDENCE: The home has an up to date statement of purpose and a service users guide that is given to service users expressing an interest in the home. The documents contain information relating to the services provided, BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 9 accommodation, facilities and the range of skills and qualifications held by staff. The service user guide was seen and those issued to existing residents contained a contract and statement of terms and conditions. A service user who had recently been admitted to the home was interviewed and able to confirm that prior to moving in she had been visited by the manager who carried out an assessment of her needs. This service users file was inspected and contained the pre-admission assessment signed by the resident to show her involvement in the process. The new resident was also able to explain how she made a decision to live at the home and what information she was given to support that decision being made. She talked of the involvement of her daughter who was invited to visit the home to see if it would be a suitable place for her mother to live. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 10 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) 7,8,10 Service users health, personal and social care needs are fully assessed and recorded. Service users health care needs are being met in the home. Service users are treated with respect and their rights are upheld. EVIDENCE: Service users records were inspected and each file contained a service user plan detailing the overall needs of each individual. The plans include information such as a social profile, medical profile and an assessment for daily living. Where possible, service users had been asked to sign the plans to show their involvement in the process. The service users plan contains a medical profile detailing any health care needs they may have. The daily records showed evidence of involvement of health care professionals such as district nurses and GP’s. GP visits were also recorded separately within the plans, giving the reason for the visit and the outcome. Service users spoken with indicated that their health care needs were being met appropriately. Comment cards were sent to health care BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 11 professionals providing services to people living at the home. The feedback was positive and answers indicated that the home communicates clearly and appropriately, staff are aware of service users needs, records are well maintained and updated when necessary and that service users are appropriately placed in the home. Two service users were interviewed, others were spoken to in passing and observation of staff and service users were made. Information gained from the various sources showed that peoples right to privacy was respected. Staff were seen to knock before entering rooms and heard to address people appropriately. Service user comment cards showed that all thirteen felt that they were treated well and that their privacy was respected. Relative’s comments indicated that they could visit in private. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 12 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) 13,14 Contact between service users, relatives and others is encouraged and welcomed in and out of the home. The management and staff at the home actively encourage people to exercise choice and make their own decisions in respect of daily living. EVIDENCE: Service users spoken to talked of relatives visiting at any time they wished with no restrictions imposed. One service user said her son comes to visit in the evening and another talked of going out with members of the family. Relatives comment cards showed that they were welcome at any reasonable time. Records maintained at the home show that visitors are frequent and varied. When interviewing staff it was evident that the principle of promoting choice was embedded in their care practice and was a value strongly held by the management of the home. Service users talked of feeling able to take control of their lives and make their own decisions in respect of daily living. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 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 standard(s) 16,18 Service users and relatives are able to make comments and complaints that the management of the home will respond to in an appropriate manner. The management of the home ensure that service users are protected from abuse. EVIDENCE: The home has a clear and accessible complaints procedure that is contained within the service users guide. The management encourage people to make comments about the service and ways in which it can be improved to meet individual need. Service users interviewed felt able to talk to both care assistants and management if they had a comment or complaint to make. The management have had no complaints in the last 12 months, however, did say that they prefer to address any issues people have as soon as they arise. Service user and relative comment cards confirmed that people know how to make a complaint if they wish to do so and that no-one has had cause to make a complaint recently. The home has a policy and procedure for the protection of vulnerable adults. The registered manager is the representative for the National Association of Care Homes (NAC) on the Vulnerable Adult Protection Committee (VAPC) and is well informed about the issues of protection. All staff working at the home have received adult protection training, evidence of which was seen on the BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 14 staff files inspected. Staff interviewed, showed an awareness of adult protection procedures. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 15 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) 19,20,26 The residents in this home benefit from having a well-maintained, safe environment to live in. Service users do have access to comfortable indoor and outdoor facilities. EVIDENCE: Bay tree is a residential care home that offers a comfortable homely environment. Resident’s accommodation is situated on the ground and first floor, with access to the latter via a lift or the stairs. Residents expressed their pleasure about the homeliness of the environment and their individual accommodation. The proprietors have a plan of maintenance and renewal that shows work to be completed in and out of the home in 2005/6. Some areas of the home have been redecorated and re-carpeted recently. The home has a rear garden that is accessible to people who use wheelchairs and to those with restricted mobility. The garden is very well-maintained and landscaped to create a very pleasant place to sit. The indoor facilities feature a large conservatory, dining room and a comfortable lounge. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 16 A tour of the home was conducted and all areas were found to be clean and tidy throughout. Service users were happy with the standard of cleanliness maintained. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 17 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) 27,28,29,30 The management of the home ensure that good staffing levels are maintained. The manager and staff are adequately trained to ensure the safety and welfare of service users. The homes recruitment practice is improving, however, there is evidence that further improvements need to be made. Service users benefit from a team of well trained staff. EVIDENCE: A copy of the homes staff rota was taken during the inspection and showed that three staff are on duty up until 5pm and that 2 staff are on duty in the evening reducing to one member of staff at night-time with a sleep-in carer as backup if needed. The registered manager is a qualified nurse and has completed a registered managers award. In order to assess standards 28, 29 and 30, four staff files were inspected. The recruitment procedures at the home are fairly sound, but with some evidence of previous out of date practice. Some files were found to omit identification and at least one person had commenced work without a completed CRB or POVA check. See requirements. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 18 The manager of the home demonstrates an excellent commitment to training and as such has produced an annual training plan and an active training programme. Staff interviewed talked of many opportunities for personal development and that they were well supported to complete further training to enhance their work practice. Each member of staff has a training portfolio containing certificates and all staff are actively encouraged to complete the NVQ 2. Training is accessed from a variety of sources which makes it varied and more interesting. New staff are required to complete an induction programme leading to foundation training and NVQ. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 19 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) 31,33,36,38 This home is run and managed by a person who is fit to do so. The home is run in the best interest of its residents and is demonstrably based on good practice. Staff are provided with an appropriate level of supervision and appraisal to ensure they continue to maintain best practice. The fire safety procedures at the home do aim to protect service users and staff, however, record keeping needs to be improved to further evidence the fact and to eliminate gaps in testing equipment. EVIDENCE: The manager is registered with the Commission and has been through a fit person assessment process that deems her fit to manage a care home of this nature. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 20 The management have introduced an excellent quality assurance system that takes into account the views of residents and their relatives by way of annual questionnaires. The system introduces a quality audit procedure that covers all elements of the service provided to enable the management to carryout a detailed analysis of the quality of service provided. As a result of the findings, the management have produced an action plan to address any short falls. This is very good practice and again, demonstrates the providers commitment to the continuous assessment and improvement of the service. This process needs to be further developed to publish the results of the audit in a report, which should be made available to service users and relatives and a copy supplied to the Commission. See requirements The manager has implemented an ongoing plan of supervision and annual appraisal. Staff interviewed confirmed that they are given the opportunity to have regular one-to-one supervision and annual appraisal which is linked to a training needs analysis. Records relating to fire safety procedures were inspected and in general were in order. However, records of weekly fire alarm testing were not up to date, although the manager confirmed that they are happening in accordance with fire safety regulations. See recommendations. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 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 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 N/A 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 N/A 13 4 14 4 15 N/A COMPLAINTS AND PROTECTION 3 3 3 N/A N/A N/A N/A N/A STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 N/A 3 3 N/A 4 N/A N/A 3 N/A 3 BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 22 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 29 Regulation 19 Requirement The registered person must maintain staff files and carryout pre-employment checks in accordance with regulation 19 and schedule 2 The registered person must supply to the Commission a report of any quality review conducted and a copy made available to service users and relatives. Timescale for action 4.07.05 2. 33 24(2) 31.08.05 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 It is recommended that records relating to fire alarm testing are maintained in accordance with the fire safety regulations. BAYTREE HOUSE I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 I55 S27308 Baytree House V227812 140605 Stage 4.doc Version 1.30 Page 24 - 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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