Inspection on 21/02/07 for Baytrees

This inspection was carried out on 21st February 2007.

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

Baytrees 18/09/08

Baytrees 17/11/05

Baytrees 29/06/05

Baytrees 30/12/04

Baytrees 18/06/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Baytrees 246 Old Worting Road Basingstoke Hampshire RG22 6PD Lead Inspector Tracey Horne Unannounced Inspection 21st February 2007 09:30 Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 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 Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 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. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Baytrees Address 246 Old Worting Road Basingstoke Hampshire RG22 6PD 01256 466 274 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) Liaise Loddon Limited Mrs Sarah Trievnor-Long Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 2005 Brief Description of the Service: Baytrees is a care home providing personal care and accommodation for 4 young adults with a learning disability. It is owned and managed by Liaise Loddon. The home is a four bedroom detached house located in the heart of Basingstoke and is within access to local shops and services as well as to shops and leisure amenities within the main town. The home has a large private enclosed garden with areas for growing vegetables as well as ample space for service users to relax. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The opportunity was taken to look around the home, view records and procedures. Due to the specific needs of the service users it was difficult to talk to everyone living at the home, but observation enabled the inspector to gain a better understanding of how the needs of service users were being met. The staff on duty during this visit felt they were supported to do their job. The commission has received information from the home prior to this visit. This has provided additional evidence to show how the home is meeting the key standards. At that time no concerns were noted and no requirements made. The fees for the home range between individuals from £2,500.00 - £3,500.00 per week. What the service does well: The staff are caring, respectful and are mindful of peoples need for privacy and dignity. They encourage individuality and independence within the limits dictated by the service users needs. The staff support individuals to make decisions about their lives and service users are fully involved in planning their lives. The staff team are committed and provide consistency to the people they support and receive regular training to be able to care for service users. The home has a logical and detailed process for recruiting new staff. One member of staff said “I feel that the training I have done so far has given me the skills I need to support service user who live here, I ask for training and I get to do it.” The home use photographs and pictures to ensure individuals have the information they need to enable them to choose what activities they wish to participate in, and what they prefer to eat each day, notice boards in the kitchen and dining room, and in individual’s bedrooms clearly stated this information. Service users are offered a variety of foods, fresh fruit and vegetables and lots of choice to enable a balanced, varied and healthy diet. The home has an open and good process in place for dealing with complaints, concerns and compliments. The registered manager’s have a good rapport with students and run the home’s in the best interests of service users. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 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 Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefited from having their needs and aspirations assessed on a regular basis. EVIDENCE: The manager said that all of the service users who live at the home have done so for many years, she explained the assessment process and the inspector read the pre admission policy and procedure. The manager said that two staff would complete the assessment with the prospective service users wherever they live. Records showed service user’s representatives were consulted in the assessment process. The home complete further assessments with service users’ to identify their needs, wishes and achievements on a regular basis. Assessments were comprehensive and addressed a full range of need areas, including how the service user communicates, clear guidelines for supporting individuals if they display behaviour that challenges others, and support required during an epileptic seizure. Individual Care Plans on file clearly related to the issues identified through the assessment process, including possible trigger causes of epileptic seizure and Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 9 behaviours, what staff need to be aware of and agreed steps to take for recovery following a seizure. Individual needs and aspirations are discussed during individual’s reviews, which are held every six months. Records showed these occurred and involved the individual, social services and the service users families if the service user wishes. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s or their representatives are involved in the preparing and reviewing of their care plans. Service users are fully supported to make decisions in all areas of their lives. Risk assessments are in place to enable service users to take risks as part of an independent lifestyle. EVIDENCE: Care plans seen were being developed further to be more ’staff user friendly’ , as staff had suggested there was a lot of information in the files which could be reduced to ensure only relevant details regarding the individuals support and care are included, therefore making it easier for new staff to read the relevant information. Care plans were comprehensive and included information about how the individual wishes to be supported in their daily activities, including a daily routine from the moment they want to get up, to the support they need when they want to go to bed, which included any specialist equipment such as a Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 11 specialist bed. Other information included personal history, religious beliefs, family relationships, dreams and wishes for the future, details of friends and important people in service users lives. The care plans included precise information about how the individual communicates, be it verbally, using sign language (which all staff receive training ) or with facial expressions, body language etc. All care plans seen had been reviewed at least once every six months, with the individual or their representative being involved in the preparation. The home use photographs and pictures to ensure service users have the information they need to enable them to make choices, and each day at key times, staff discuss with the service users (on an individual basis) what activities they wish to do during the morning, and again after lunch for the afternoon and evening. Once the service user has decided, staff place a picture of the activity on the service users daily activities form. A notice board in the kitchen and dining room has photographs of what service users have chosen to eat. Staff spoken with were able to demonstrate an understanding of the need to support service users to make their own decisions, this is also covered during new staff induction. Staff said it is important to offer choices to individual’s to enable them to decide what they want, one member of staff said ‘I can tell a lot about what people think by their body language and facial expressions, we try to enable many different opportunities for service users, and their reactions inform us of what they think.’ The manager explained parents and key multidisciplinary team members attend Person Centred Planning (PCP) groups run by the provider, to show relatives how the home is meeting the individual’s needs. Staff were aware of how to access advocacy services should any service user need to, however at present the manager said no service user has expressed a wish to speak with an advocate. The Statement of Purpose and Service User Guide were clear about the rules in the home and each service user had a copy. These also contained information on who service users could talk to if they were unhappy about any aspect of the home. Both documents were produced in an easily accessible format for service users who had some difficulty reading. Risk assessments were seen for two service users and covered every activity that the service user participates in, such as going for a walk, horse riding, accessing shops etc, these are reviewed regularly. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual’s are supported to take part in age appropriate activities within the home and local community, and are supported to maintain appropriate personal, family and other relationships whilst respecting individual’s rights and dignity. Service users are offered plenty of fresh food with lots of choices to enable a balanced and healthy diet. EVIDENCE: Individual preferences regarding activities and cultural beliefs are recorded in their care plans, daily activities are recorded in individual’s daily notes. These ranged from going shopping, parties, pub lunch and going out for lunch with family members. One service user told the inspector how much he enjoys horse riding. The activities which service users have participated in are recorded weekly, and include hobbies such as puzzles, horse riding, computer Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 13 work (touch screen programme) housework, cooking, massage, walks, karaoke, pub and shopping. The home also uses evaluation sheets to record service users’ general mood, incidents, communication, food and drink intake and support given with personal hygiene, this is recorded after the morning and evening shifts. On the day of the inspection service users were participating in various activities within the home, listening to music, having a hand and foot massage, playing on the computer, and going to the local supermarket, and spending time with staff. Service users are supported to complete session feedback forms when they have completed an activity, staff said this enables a record of likes and dislikes, and tracks achievements which are discussed at the six monthly reviews. Service users are involved in the Award Scheme Development and Accreditation Network (ASDAN) and the AQA Unit Award Scheme, certificates are produced to show individual’s achievements. One service user spoken with said they have regular contact with family members, the visitors’ book and daily records reflected this. Staff spoken to also said families keep in touch by telephone. Staff said the home welcomes visitors. The inspector saw the menu displayed for meals on the day, although it didn’t show an alternative, the cupboards, fridge and freezer were well stocked, which would enable choice and variety and included fresh fruit and vegetables. Staff said they ask service users on a daily basis if they would like to eat what is on the menu, which is decided with service. A four week menu was included with the pre inspection questionnaire, which showed a balanced diet, which met individual’s preferences and dietary needs. The inspector saw records of all food eaten, staff said these records are kept to ensure service users eat a balanced diet. Service users were seen to be enjoying their lunch in a relaxed and unhurried atmosphere. A cook is employed, service users are encouraged to prepare meals with staff guidance, as per their care and development plans.. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive support in a way that they prefer, care plans are reviewed to ensure this information is current. Staff follow the home’s procedures to ensure Service user’s physical and emotional health needs are met. Service users are protected by staff who receive appropriate training for the safe administration of medication. EVIDENCE: Details of personal support and personal preferences are written in individual plans. For example, how individuals communicate, like to be woken etc. The emotional welfare of service users appeared to be crucial in all aspects of their lives. The home has developed ways of supporting people to express their emotions, for example, through pictures, spending quality one-to-one time with staff. Strategies for supporting people with their emotions have also been developed and seem to be working very well. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 15 Service users have access to a range of medical and health care professionals, records seen confirmed consultation with doctors, district nurses, care managers, epilepsy nurse, chiropodist, optician, physiotherapists etc. The manager said other specialists are consulted as required. All drugs were securely stored and administered in accordance with an in house and corporate medication policy and procedure. Records of administration and disposal of unwanted drugs and medicines seen were available complete and accurate. A pharmacist via a monitored dosage system dispenses all drugs administered in the home. At the time of this visit, the manager said no service users self-medicates their medication due to the individual’s needs. Records seen confirmed all staff administering drugs and medicines had received training. The manager said new staff receive training and ‘shadow’ trained staff to witness the medication procedure prior to being assessed by the manager before completing medication. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for protecting service users and responding to concerns are good. EVIDENCE: The home had a formal complaints log to record concerns and complaints. The information received prior to this visit stated that the home had not received and concerns or complaints, the manager confirmed this. Staff said they were aware of the homes procedure for dealing with complaints efficiently, and communicate effectively with service users to find out if they are happy or not. The staff said that they receive training in the prevention of abuse of vulnerable adults, certificates confirmed this. The home has a copy of the Hampshire County Council ‘Protection of Vulnerable Adults’ policy and procedure, and the Department of Health’s (DOH) ‘No Secret’ guidelines’. All service users have their own bank accounts. The system for handling and recording service users monies was looked at. Receipts are kept where possible and service users are supported to handle their own money on an individually assessed basis. The inspector looked at the financial records of two service users who live in the home, all were correct when checked against money held. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home and accessible garden is provided for service users which meets their needs. EVIDENCE: The home is well maintained and meets the service users needs, the secure garden appeared well maintained and is accessible to service users. The home employ a ‘handy man’ who ensures all maintenance requests are dealt with The manager has requested that all windows and doors (external) are replaced, and new dining room tables and chairs are bought within 2007/08 financial year, and that the outside of the home is re decorated. The manager explained service users are encouraged choose the colour scheme for their bedrooms and furnish the room with personal belongings, furniture and pictures to make it feel like home. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 18 The inspector saw communal areas were clean, bright and warm, furnished to the individuals taste and personalised with photographs of individuals and staff participating in various activities. The home appeared clean, no offensive odours were detected. Staff said they have completed infection control training, and were aware of the home’s policies and procedures of hygiene issues. The inspector saw records of staff training and the member of staff who was cooking confirmed they were up to date with food hygiene training. The home’s radiators and pipe work are safe ensuring that all potential hot surfaces are kept to low temperature. The washing fitted had a high temperature programme (in excess of 65 degrees c) and sluicing mode. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Students individual and joint needs are met by skilled, trained staff in sufficient numbers. Students are protected by the homes recruitment and selection practices. Staff receive mandatory and specialist training and are supported to obtain NVQ level 2 or above. EVIDENCE: Staff told the inspector they feel they have ample training to enable them to do their job properly. Records of staff training reflect this and show staff have received training in adult protection, health and safety, manual handling, first aid, food hygiene, epilepsy, infection control, person centred planning, autism, fire awareness. Staff members interviewed confirmed they received a good quality of training and personal development that was relevant to meeting the needs of service users. The PIQ included a training course calendar from jan’06-apr’07, which included mandatory and specialist training, again staff confirmed they have either already attended, or are booked onto a course to complete this training. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 20 The pre inspection questionnaire stated that only 25 of staff have an NVQ level 2 or above award, fifteen care staff are employed in total. The manager said the figure is more like 70 of staff have NVQ 2 or above now. It was evident from practices and interactions observed that staff had developed good relationship between themselves and service users. The manager confirmed the home’s induction programme has been assessed against the Skills for Care Council induction standards, and that all new staff complete the Learning Disability Award Framework (LDAF) award before starting an NVQ award. Staff said they have received the following training specific to enable them to meet the needs of service users living in the home, ‘proact SCIPr uk’, induction & foundation, communication, Adult protection, understanding learning disabilities, epilepsy & understanding Autism. The manager showed the inspector a computer programme which the home use to store employee’s information (Caresys). Staff recruitment and other confidential staff files are maintained in a lockable cabinet in the managers office. This documentation has been inspected during the last inspection visit and was maintained to the standards in line with best practice. The manager confirmed that there had been no changes to selection and recruitment procedures at the home, and it was confirmed that these processes support and promote the protection of the people living at the home. Staff interviewed confirmed that all checks had been carried out in regard to CRB and POVA, and that two references had been provided and followed up by the home. The manager who is directly involved in these processes was also able to confirm best practice, and clear policies and procedures were found to be in place to guide staff. The manager explained that all new staff files containing their references and proof of identification is kept at the head office, as they collect all of this information, and send it to the manager of the home when all of the information is complete, a telephone call to the head office confirmed that the most recently employed staff has all of the relevant documents, and is completing the company induction before commencing work within the home, the manager is aware that as part of the next inspection, this may be confirmed visually by an inspector. On the day of the inspection there were sufficient staff members on duty to meet individual’s and group needs. Staff members provide waking cover during each night shift. The staff team undertake the cleaning of the houses during weekends, with the service users assisting where possible. Staff explained that they could “always do with” more staff to help them, especially when all four service users wish to go out and participate in different activities, staff said they compromise, but they are never left in situations were they feel unsafe or at risk. Given the complex needs of many of the service users obtaining the levels of staff to meet the expectations of all individuals at all time is likely to remain illusive. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and competent to run the home. Management and administration of the home is based on openness and respect. Service users views are sought frequently, and are protected by staff being well trained and showing a sound knowledge within the areas of health and safety. EVIDENCE: The registered manager has completed her NVQ level four in management, has almost completed her Registered Managers Award (RMA) and is an NVQ assessor. The home is well run and staff spoke highly of the management and support within the home. Paperwork is well organised and all policies and procedures are reviewed annually. Service user reviews are held six monthly Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 22 and the views of parents, funding authorities and other relevant professionals are taken into consideration when reviewing the service provided. Annual health and safety checks are undertaken by the registered manager and suitable training is undertaken by staff for example, fire safety run by the fire service and first aid training with advanced courses for the designated first aid staff Staff said the manager is very supportive and her approach creates an open, positive and inclusive atmosphere. Discussions with staff and observations showed there are clear lines of accountability within the home, the management structure consists of manager, team manager, positive support manager. The home arrange monthly staff meetings, one staff member said the majority of staff attend. The responsible individual completes monthly unannounced audits to comply with regulation 26 of the care homes regulations 2001, a copy of these reports were available in the home, and would be sent to the Commission on request. These documents report on the conduct of the residential service provided. The Responsible Individual confirmed that there is a refurbishment plan for the homes, which includes re-decoration and refurbishment work. The home are reviewing their quality assurance procedure to fall in line with the Annual quality assurance assessment (AQAA), which will be sent by CSCI for providers to complete. The staff are continuing to improve ways in which they can ensure service users’ views are obtained, they use a wide range of pictures to encourage service users to communicate, service users appeared very relaxed and seemed to enjoy staff company. The staff complete regular weekly health and safety checks to ensure the safety of the building. Certificates were seen to show regular servicing of the boiler, electrical items, fire safety equipment and liability insurance. All Control Of Substances Hazardous to Health (COSHH) sheet corresponded with the cleaning chemicals used in the home. There were various health and safety procedures in place within the kitchen including colour co-ordinated chopping boards, gloves, temperature recording including probing of food, fridges and freezers. Records of staff attending fire training and practices had been completed, staff explained the evacuation procedure to the inspector, who saw records of regular fire alarm and fire safety equipment tests had been completed. The homes have a policy and procedure informing staff members on health and safety. A sample of policies and procedures was seen and it showed that these are reviewed regularly. There is a system in place that ensures that all appliances are serviced, records and certificates seen indicated that the electrical equipment received regular servicing and maintenance. The employer’s insurance liability certificate was displayed and current. Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 23 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 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 24 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. 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 Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Baytrees DS0000012415.V323714.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!