Inspection on 31/01/06 for Baytree House

This inspection was carried out on 31st January 2006.

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 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 14/06/05

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 Unannounced Inspection 31st January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Baytree House Address 423 Unthank Road Norwich Norfolk NR4 7QB 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) 01603 458503 01603 503528 Mr Thomas Paul Hanley Mrs Sandra Elizabeth Hanley Care Home 16 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (16) of places Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 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 DS0000027308.V281908.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took approximately 3.5 hours to complete. The manager/proprietor was available throughout the inspection and very helpful in facilitating the process, as were the staff on duty. During the inspection a tour of the premises was completed, a number of residents and staff were spoken with and records relating to staff, service users and the running of the home were inspected. This report covers the assessment of a small number of key standards that were not inspected on the last occasion. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 Standards not assessed on this occasion. EVIDENCE: Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The home has good medication management systems in place. EVIDENCE: This standard was assessed with the assistance of the senior care worker who was responsible for the medication on the day of inspection. The home has a policy and procedures for medication management that is stored in an easily accessible place. There were no service users self-administering medication, however there are procedures to ensure that if the situation arises, risk assessments will be carried out. Each service user has a lockable facility in their room. Records for the receipt, administration and return of medicines were inspected and found to be in good order. The home uses the Nomad system and receives weekly deliveries from the local pharmacy. All medicines not contained within the nomad system are stored in individual containers labelled with the Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 9 resident’s name. Staff monitor these medicines to ensure that they do not accumulate excess stock. Full medication audits are completed once a year as part of the quality monitoring process and spot checks are conducted to ensure good practice is being maintained. Controlled drugs are stored in a metal cabinet that complies with the misuse of drugs (safe custody) regulations 1973. A register is maintained and the administration of controlled drugs is always witnessed by a second person. The home did not have any residents requiring controlled drugs at the time of inspection. All staff with the responsibility for the administration of medicines have attended the Boots medication training course. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 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 the following standard(s): 12, 15 The home delivers a programme of activities determined by resident’s expressed interests. Wholesome and varied meals are provided in a choice of pleasant surroundings. EVIDENCE: Individual’s interests and hobbies are assessed on admission and included in a social care plan. Key workers review the plan monthly and any changes are noted. The home aims to meet individual needs where possible and has met various requests, such as clothes shows, shoe shows and musical groups. Some residents have recently started to go to the theatre, at their request. The weekly programme of activities includes extend classes and reminiscence sessions both provided by professionals employed by Norfolk County Council. Other activities include skittles, bingo, and walks in garden, watching videos, manicures and one-to-one sessions. Activities are publicised using the homes newsletter, issued when needed throughout the year. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 11 In respect of meals, the menus were inspected, the main meal of the day was observed and service users were spoken with. Menus are drawn up on a four weekly basis by the manager and the cook using feedback from residents about their likes and dislikes. The menus only show one choice of main meal, however records showed that people are offered alternatives dependant on what is available. Breakfast and tea options are varied and people have lots of choice at these times. Residents spoken with said that they always enjoyed the food served and particularly, the good selection of fresh vegetables. They did not necessarily know what they were having for lunch before it arrived but found this entertaining and were very happy with the system. When discussing meals with the cook she was able to show records of peoples diet and any variations. She also discussed any special dietary requirements people may have and how she catered at these times. For instance, there are three people on soft diets where meat is liquidised to make it manageable. People’s nutritional needs are assessed on admission and the information arising from the assessments is given to the cook so she may plan accordingly. There is a range of places that people can choose to eat, one resident was in her bedroom and another in the lounge. Some residents were eating in the conservatory and others in the dining room. The conservatory is a nice bright airy place to eat whilst the dining room is very homely. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 Standards not assessed on this occasion. EVIDENCE: The standards were not assessed on this occasion, however, the home has not received any complaints since the last inspection. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The home has systems in place to ensure the environment is safe and kept clean and tidy. EVIDENCE: This is a small home situated in its own grounds, with a large nicely maintained garden to the rear and a car park to the front. The environment is very homely and creates a nice atmosphere. There is one communal lounge with a TV and facilities for playing music, a large conservatory with doors leading to the garden and a separate dining room. The décor throughout the home is good, however some areas are in need of refreshing. The manager has a plan of maintenance and renewal that runs from September to September and some redecoration has been included. A tour of the home was conducted and all areas were found to be clean and tidy, the bathrooms were a little cluttered, but with items that were being housed temporarily. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 14 Domestic staff are appointed to keep the home clean, they work Monday to Saturday and Sundays are covered by care staff. Domestic staff are provided with training in infection control, COSHH, food hygiene and have recently completed some external training in working and operating safely. The lead domestic was available for a discussion about the cleaning routines. She was able to show cleaning schedules that help to organise their work in order of priority and act as a checklist of tasks to be completed. The cleaning schedules are split into daily tasks, weekly tasks and monthly tasks. The domestics are also responsible for completing daily health and safety checks. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 The homes recruitment practice has improved since the last inspection and now demonstrates the home acting in the best interest of residents. EVIDENCE: This standard was not fully assessed, however, compliance with the requirement made at the last inspection was assessed and is met. The staff file relating to a new employee was inspected and found to contain all the necessary pre-employment checks. The manager now understands the requirements in this respect. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 The home has a good quality assurance system in place and is committed to self-monitoring and continuous improvement. The home has systems in place to protect residents from the risk of financial abuse. EVIDENCE: This standard was assessed in full at the last inspection. It was established that the home has an excellent quality assurance system in place. However, a requirement was made in respect of publishing the results of the quality audit in a report. This requirement has been met and the management have provided residents with access to the report and the Commission with a copy. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 17 The home does not manage resident’s finances and does not hold any money. Each resident is provided with a lockable facility in which to store money and valuables and people are encouraged to use the facility. The home advises that any very valuable items are placed in the bank for safekeeping or with family where appropriate. Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X 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 X X 4 X 3 X X X Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Baytree House DS0000027308.V281908.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Norfolk Area Office 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. 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