Inspection on 03/01/06 for Baytree House

This inspection was carried out on 3rd January 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Baytree House 18/02/09

Baytree House 05/03/08

Baytree House 04/12/06

Baytree House 11/07/05

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 Devon TQ2 5UE Lead Inspector Sam Sly Unannounced Inspection 3rd January 2006 8.45 Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 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 Baytree House DS0000037128.V276407.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 Adults 18-65. 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 DS0000037128.V276407.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Baytree House Address Torbay Council 22 Croft Road Torquay Devon TQ2 5UE 01803 211300 01803 380164 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) Torbay Council Mrs Nina Ann Down Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users with Learning Disability who may have additional Physical Disability and/or Sensory Impairment. Service Users aged 16 or 17 years may also be admitted. Date of last inspection 11th July 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 are 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 DS0000037128.V276407.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was unannounced and took place between 8.45am and 1pm on a weekday in January. It included talking to all but one resident, all staff on duty, and the registered manager. A tour was made of the premises and care records, staff files and health and safety documentation was examined. What the service does well: What has improved since the last inspection? What they could do better: Care plans, assessments and risk assessments must be regularly reviewed and updated to reflect the current needs of residents and record how staff are going to meet these needs. The registered providers 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 Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 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 the following standard(s): 2 Residents can be sure their needs are well assessed before admission. EVIDENCE: Three resident’s care plans were examined and there was a clear assessment format, which had recently been improved. All residents had an assessment before admission, which involved gathering information from parents and Local Authority care managers. Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 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 the following standard(s): 6&9 Residents changing needs are not consistently recorded in plans and risk assessments to guide staff. EVIDENCE: Resident’s needs were well understood by staff, and the care plans and risk assessments examined covered a comprehensive range of needs, however some of the care plans examined had not been updated and therefore did not reflect the current needs of the residents. One risk assessment had also not been updated to reflect information recorded in daily recording documents, and another recorded a potential risk but did not specify how staff should act to minimise this risk. There was evidence within key worker records that staff met regularly with residents and their representatives to discuss their care needs and future goals. Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 14 & 15 Resident’s enjoy a range of leisure activities and are encouraged and supported to maintain family contact, friendships and relationships. EVIDENCE: Some resident at Baytree House are on short term breaks, with a few living at the home. Staff support residents to continue with leisure activities they enjoy. One resident said she continued to go to Clubs she was a member of, and was supported by staff to go into Torquay to the shops. There were activities to do at Baytree House like pool, a computer, board games, art and craft, T.V, a monthly disco and cooking. Staff also took residents out on trips, visited local attractions, and to evening and social events. Those residents living at Baytree long-term had been on holidays last year. Family contact is an integral part of the service at Baytree, with regular contact between staff and families about respite stays. The long-term residents are also encouraged and supported to keep in touch with family and friends regularly by phone or visits. Baytree House has a welcoming atmosphere, and Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 11 visiting is encouraged. The registered manager runs a relationships course, which helps residents develop and maintain positive personal relationships. Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 19 Resident’s health care needs are well understood and met by staff at Baytree House. EVIDENCE: For those residents receiving respite care, health needs are well understood by staff, with specialist training provided is necessary; all staff working attend epilepsy, person centred awareness and total communication training due to the needs of residents. However, the general health checks and appointments were left to parents to organise. Long-term residents health care needs were well-understood and appropriate appointments and check ups arranged. There was evidence of the appropriate use of healthcare professionals to advise of medication, and health related issues. Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 22 & 23 Concerns are complaints are taken seriously and dealt with swiftly, and residents are protected from abusive situations. EVIDENCE: There was a clear complaints procedure that was accessible to residents. Discussion with the registered manager, and records showed that concerns and complaints were dealt with swiftly and appropriately. There were a range of adult and child protection policies and staff interviewed were clear on the procedure for reporting abuse, however staff had not yet attended formal adult protection training. The registered manager contacted Torbay Council’s training department during the Inspection and booked places for all staff before March 2006. Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 14 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 the following standard(s): Baytree House is clean, safe and comfortable, and once the annexe is completed will have the facilities to meet the needs of a range of residents. EVIDENCE: The environment at Baytree was clean, well decorated and well furnished, with a maintenance person available to do any jobs required. There has been no fire or environmental health Inspections since the Commission’s last Inspection and regular environmental risk assessments were taking place. The annexe was in the midst of being re-plastered after major building work to prevent future flooding. It will then have a new kitchen and furnishings and be able to be used for developing resident’s independence skills. This work should be completed by February 2006. The garden had been landscaped by the a local day service project, and looked good, however, the path allowing access to the garden had not been finished so residents could not safely use it. There were sufficient systems and procedures in place to control the spread of infection, and the laundry was clean, however there was some flaking paint and holes in the plaster on the laundry walls that could harbour infections. Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 15 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 34 Staff were competent and qualified and recruitment practices protect residents. EVIDENCE: Three new staff files were examined and found to contain all the necessary identification, fitness checks and documentation. Residents were involved in the recruitment process at interview. Staff observed were approachable, genuinely enjoyed working with residents, were interested, motivated and committed to their jobs. Staff said they were provided with a range of specialist learning disability training, which helped them do their jobs, and were involved as key workers in reviewing resident’s needs. Over half the care staff at Baytree had attained, or were working towards NVQ 2 or above. Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 16 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The registered manager is competent, qualified and experienced, and the home is run safely and well. EVIDENCE: The registered manager has many years of working in and managing services for people with a learning disability, and keeps her practice up to date by attending training and running groups. She has completed her NVQ 4, but due to problems outside of her control is still awaiting confirmation of completion. All the required health and safety training is provided for staff including moving and handling, first aid and food hygiene. Health and safety records for fire safety, environmental risk assessment, Legionella, accidents and electrical items are all up to date. Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 17 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 3 X X X X 3 X Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 18 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. 2. Standard YA9YA6 YA43 Regulation 15 & 13(4) 26 Requirement Care plans and risk assessments must be regularly reviewed and updated. Regular monthly provider visits to the home must take place with copies of outcomes sent to CSCI (Previous requirement timescale 18/08/05 – not met). Timescale for action 09/03/06 09/02/06 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 Refer to Standard YA23 YA30YA24 Good Practice Recommendations All staff should have attended training on Adult Protection. The building work on the path into the front garden should be finished, to make the garden safely accessible. The areas identified at the Inspection on the laundry walls should be sealed and repainted. All staff that handle food should have Food Hygiene training. 3 YA42 Baytree House DS0000037128.V276407.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Ashburton Office 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 DS0000037128.V276407.R01.S.doc Version 5.1 Page 20 - 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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