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Inspection on 21/01/08 for Baytrees Nursing Home

Also see our care home review for Baytrees Nursing Home for more information

This inspection was carried out on 21st January 2008.

CSCI found this care home to be providing an Poor service.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents expressed satisfaction with the activities in the home, as did the surveys. One relatives survey commented, " Residents come back in high spirits following outings." Satisfaction was also expressed in the varied menu they receive. Staff offer care in a kind and dignified manner.

What has improved since the last inspection?

A small consulting room is in use for private meetings. An activities coordinator has been employed. General practitioners are regularly consulted, as is the multiple sclerosis specialist. Three of the four requirements of the last inspection have been met; attempts have been made to meet the other.

What the care home could do better:

The system of managing residents` money does not safeguard them from financial abuse. The shortfall in hygiene standards in the kitchen and laundry means the health, safety and welfare of residents are not promoted. The home needs to supply the specialist beds and equipment required to meet residents assessed needs. The home needs to complete the requirements of the recent fire authority inspection. The home to ensure training is converted into practice as in the case of managing resident`s money.

CARE HOME ADULTS 18-65 Baytrees Nursing Home 1 Highfield Road Worthing West Sussex BN13 1PX Lead Inspector Unannounced Inspection 21st January 2008 10:00 Baytrees Nursing Home DS0000024113.V347503.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 Nursing Home DS0000024113.V347503.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 Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Baytrees Nursing Home Address 1 Highfield Road Worthing West Sussex BN13 1PX 01903 693833 01903 693822 baytreeshomes@aol.com 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) Bay Trees Homes Limited Mrs Denise McWilton Care Home 30 Category(ies) of Physical disability (30) registration, with number of places Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Only service users in the category Physical Disability (PD) 18-65 years may be admitted. Rooms 21 and 27 can only be used for service users who are not independently mobile through the use of a wheelchair. 2nd May 2006 Date of last inspection Brief Description of the Service: Baytrees is a care home proving nursing care and accommodation for 30 younger adults with physical disabilities. Baytrees Homes Limited owns the service and the Responsible Individual on behalf of the company is Mr T Francis. The home is located in Worthing and is close to shops, pubs and other amenities. The main house consists of a three-storey building, which has been extended and adapted. In 2004 a new extension for 10 service users was added to the premises this increased the registration to 30 service users. All rooms in the new extension and a small number of rooms in the main house have en-suite facilities. All rooms are accessible by a passenger lift. Service users have level access to two lounges/dining rooms, a conservatory, a smoking room and a large decked area to the rear of the property. The fees charged are £500-£900 Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit as part of the inspection process took place on the morning and afternoon of 17th January 2008. The deputy manager facilitated the inspection. The Commission for Social Care Inspection (we) were in receipt of an Annual Quality Assurance Assessment (AQAA) and most documents required on the day were made available. Twenty-six residents were accommodated on the day of inspection. We were in receipt of seven surveys from relatives, five from staff and four from professionals, most of the comments made were positive. Documents, care plans and medicine administration charts were inspected. Residents were also spoken to and they expressed satisfaction with most aspects of the home saying that staff were very caring. All residents spoken to throughout the day stated great satisfaction in the care they receive, that they are always treated in a respectful manner and that they enjoyed the activities provided. A relative spoken to on the day also stated satisfaction with the care his son receives in the home. Several shortfalls in meeting standards were identified. These are summarised below and detailed in the body of the report. All of the above information was used in compiling this report, The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. What the service does well: What has improved since the last inspection? Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 6 A small consulting room is in use for private meetings. An activities coordinator has been employed. General practitioners are regularly consulted, as is the multiple sclerosis specialist. Three of the four requirements of the last inspection have been met; attempts have been made to meet the other. 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 Nursing Home DS0000024113.V347503.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 Nursing Home DS0000024113.V347503.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): 1,3 People who use this service experience adequate outcomes area as needs are assessed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Physical and nursing needs are assessed prior to admission and were seen recorded in the care plans. There was little evidence of social needs and preferences being assessed and recorded. Copies of Care Management assessments undertaken by local authority are also held of individual care plan files. A service user plan is developed based on the assessed needs and risk assessment is in place. The Statement of Purpose and Service User Guide were unavailable on the day of the visit. Three relative surveys received commented that enough information was always available to help them make decisions, three commented usually and one commented sometimes. Some residents have bought their own specialist beds and pressure relieving equipment, this is not explicit in the home brochure seen which states “ the home is fully equipped to provide high levels of nursing care to physically disabled young adults”, neither is it explicit in the contract/terms and Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 9 conditions. The AQAA states that plans for improvement in this area are “not applicable”. Baytrees Nursing Home DS0000024113.V347503.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 People who use this service experience good outcomes area because assessed care needs are met and residents have choice and can take risks in daily life. The assessment and recording of social need and personal goals is not in place This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents have a plan of care based on an assessment of need. The plans inspected gave clear information on meeting physical need, such as hygiene, continence and pressure care and managing risk but little information on social need. How much the residents and/or their representative is involved in drawing up the plan was unclear. There is regular review of the plans. There is not a key worker system in place and the plans are not available in any user-friendly format, for example large print or graphic. Residents spoken to stated that all need are met to their liking and they have choice in daily life. Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 11 There was recorded evidence of risk assessment in the plans. This covered areas such as privacy, falls, medication, choking, skin condition, adverse reactions. The use of bedrails is discussed with families. Residents spoken to stated that all needs are met, a relative spoken to stated that his son’s needs are met. A professional surveyed comment that her client “appears to be supported as much as possible to live his life in the way he wants to”. Baytrees Nursing Home DS0000024113.V347503.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): 12-16, 17 People who use this service experience good outcomes area because there are appropriate and varied leisure and dietary provision. Rights are respected and responsibilities recognised in their daily lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken to stated that they are happy with the recreational activities available in the home. An activities coordinator is employed in the home. The home has its own transport and the residents enjoy frequent trips out. One survey received stated that the trips are very good, another said the home provided good activities in a friendly atmosphere. Upcoming events are displayed on the notice board. The benefits of placing the notice board lower, to make it more accessible to wheelchair users and to make the information more accessible by using different formats was discussed with the deputy manager. Residents were spoken to and they stated that they were happy with the activities in the home. Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 13 One survey received stated that birthdays and seasonal events are always celebrated and that residents have a full and varied life. The activities coordinator was observed interacting with the residents both individually and in a group activity. When she was spoken to she demonstrated a knowledge of the residents but she does not keep records of individual social and recreational preferences. There are not any links at present to any educational or recreational facility such as local colleges or gyms/day centres. Family and friends are welcome in the home. One relative was seen making tea, there are drink-making facilities in the lounge, staff were observed chatting in a friendly manner with visitors. The relative spoken to stated that he is always made welcome. Four of the seven relatives surveys returned commented that the home helps their relative stay in touch, two commented usually and one commented-sometimes. Staff were observed talking to residents in a respectful manner and were seen to knock before entering residents rooms. Residents have the ability to sit in the main communal lounge/dining room, there is also a further lounge and conservatory and one small sitting room for more private appointments. A computer is available in an area of the hall for resident use. The AQAA states that the home plans to introduce regular physiotherapy and swimming. Residents are offered a nutritious and varied menu. There is choice at each meal. Those requiring soft or pureed food are offered their food in an appetising manner. Fruit smoothies have been added to the menu to offer variety and flavour. Assistance is offered in an appropriate and respectful manner. Fresh fruit and vegetables were seen in the food store. Residents spoken to stated that they enjoyed the meals. A member of staff did comment that the residents get angel delight a lot, which she feels may be boring for them. Baytrees Nursing Home DS0000024113.V347503.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): 18-20 physical and emotional health needs are met. Residents can retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. People using this service experience good outcomes in this area because they receive personal support in the way they prefer and can retain their own medication if they choose. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal support required is noted in the care plans and residents confirmed they receive support as they wish. One relative survey commented that the home provided very little physiotherapy; another commented that there could be more mental stimulation. The AQAA stated that the home is intending to employ a physiotherapist Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 15 Staff spoken to stated that the home is run in the home is run in the best interests of the residents.and is very friendly but they sometimes feel pressured to provide all care due to staff shortages. Although the terms and conditions state that residents medicines must be stored and administered by matron the deputy manager stated that risk assessment is in place to enable residents to self-administer if they wish. There is not any resident doing this at present. Medicines are stored and administered appropriately. Medicine administration charts inspected were up to date. Baytrees Nursing Home DS0000024113.V347503.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 People using this service experience poor outcomes in this area because the complaints procedure could be in better position and format to enable people who use the service to have better access to it. Complaints that could be safeguarding issues must be referred to Social Services to protect individuals. Financial practices harm some individuals. The money of people who use the service is not appropriately handled. This judgement has been made using available evidence including a visit to this service EVIDENCE: The home has a complaints procedure in place detailing actions to be taken. It is out of date with reference to the “nursing homes Regulation and inspection unit” The procedure on display is not in user-friendly format such as picture format and could be lower to be more accessible to wheelchair users. Residents spoken to stated that their complaints would be listened to and acted on. Four surveys commented that the service always responded appropriately to complaints, one commented–usually and two commented that they had not ever raised a concern. The record of complaints was inspected, the outcome was not clearly recorded and some complaints would indicate a referral to Social Services under safeguarding adults but this had not occurred. The recording of all stages of complaints will be a requirement of this inspection. Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 17 There is a copy of the new Sussex Multi Agency Policy and Procedure for Safeguarding Vulnerable Adults. The home does not have procedures of their own to assist staff in responding to suspicion of abuse or evidence. Safeguarding adults training is in place and was last held 27/10/07. There is a financial risk assessment in place but in practice residents’ finances were poorly managed. The allowance sheets for residents did not match the amount in the pooled tin. This is detailed in the Conduct and Management section of the report. An equipment log inspected showed that residents assessed as needing a Nursing bed (Profile) and pressure-relieving equipment (air mattress) had bought their own. This is detailed in the environment section of the report. Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 18 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, 29, 30 People using this service experience adequate outcomes in this area because although they live in a homely environment there were shortfalls in kitchen and laundry facilities and hygiene and residents are buying their own specialist beds. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The communal areas of the home were neat clean and free from offensive odours. Bedrooms are personalised and residents spoken to stated that they were happy with their accommodation. There are recreational facilities; television, music, a computer and drinks making facilities available. Radiators were not covered and risk assessment on residents in rooms with uncovered radiators is not in place. The home is working towards meeting the requirements of a recent fire authority report. A shower on the top floor did Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 19 not have a radiator but had a small fan heater which when turned on did not warm the room. Risk assessment for use of this shower room is also not in place. The wood lining the shower area was degraded. An equipment log inspected showed that at least eight current residents had bought their own nursing bed and pressure relieving equipment. There was not an adequate explanation on the day as to why this was the case and the registered manager when spoken to on the telephone stated that for some residents this was their personal choice. The need for care homes offering care to people with physical disabilities to ensure that specialist adaptations and equipment are provided to meet individually assessed needs was discusses with the deputy manager and the registered manager. The kitchen-cleaning schedule was not up to date. The back wall panel of the cooker was dirty as was the oven with old burnt on matter. The taps on the sinks were dirty. In the food store room there was build up of ice on the meat freezer suggesting an inadequate seal. The milk fridge had fungus on the seal. Some left over vegetables were not labelled and dated and another bowl of food had three dates on it. Some defrosting meat was seen on a trolley with rice and jars of sauce indication a lack of knowledge of food storage and management. It was a requirement of the last inspection that the laundry be kept in a good state of repair and to this end the floor was covered with a paint to make it water resistant. The floor remains uneven and is not impermeable. The brickwork walls are also damp damaged and not impermeable. An anteroom constructed outside the laundry is not weather proof and had a pool of rain water on the floor it roof was also water damaged and there was evidence of mould. There is not adequate hand washing facilities in the laundry, the only sink being a large one for the hand washing of clothes. The soaking of clothes for lengthy periods, up to 24 hours, poses a risk of infection. Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 20 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 People using this service experience good outcomes in this area because they are supported by a competent and caring staff and recruitment procedures are robust This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three relatives surveys and one staff survey stated that at times the home is short staffed. Staff training is up to date and staff supervision is in place. There is a staff induction programme; all areas of practice are signed off. Residents spoken to stated that a caring competent staff meets their needs and that when they request assistance they do not have to wait. Staff files inspected contained identity documentation, Criminal Records Bureau Clearance and POVA check, two references and evidence of training and supervision. Two staff have National Vocational Qualification (NVQ) level 3 and a further staff member is currently working towards it. Two staff have NVQ Level 2 and a further nine are completing this qualification. Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 21 Staff have been trained in safeguarding issues there were shortfalls in putting this into practice such as making referrals regarding safeguarding adults to social services and in relation to the management of residents money. These are detailed in the Complaints and Protection and Conduce and Management sections of this report. Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 22 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, 40, 42, People using this service experience poor outcomes in this area because there are shortfalls in the management of residents’ money and in the hygiene of the home. This puts them at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has worked at the home for more than 10 years and has been registered with the Commission since November 2005. She is a registered nurse. She also has an NVQ Level 4 and completed the Registered Managers Award. Residents spoken to stated that they are happy with the day-to-day running of the home and that they are listened to. They also said they enjoyed good relationships with the manager and staff who are friendly and helpful. Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 23 Surveys received confirmed this. Residents are not consulted however in how their money is managed. The AQAA states that a management of service users money, valuables and financial affairs is in place but was not available in the policy folder on the day. Significant shortfalls in the handling of residents’ money were identified. Residents’ money is pooled in a cash box and used generically. Receipts are not accurately recorded e.g. a taxi bill, WORTAX for £13.00 not dated or individualized, therefore there was not any clear indication of whose money this was taken from. Residents without any money of their own are allocated money from this tin and one had a negative balance of £57.17, this is evidence that residents’ money is being borrowed without their knowledge or consent. Some residents allowance sheets were recorded as having balances of up to £50 but there was only £1.00 and some pennies in the box. We were informed that this money is also used for other purchases, such as when the home runs out of milk at the weekend. A generic pharmacy bill was also paid from the tin. Only three residents had products on this bill. There were irregularities in the way this was recorded on their allowance sheets. These sums of money used for milk and pharmacy bills are not specifically returned to the tin. There was not an adequate explanation as to why a resident was buying a product that is available on prescription. Any money held in the bank for residents is in the Baytrees account and not in individual accounts. This will be a requirement of this inspection. The AQAA received from the home was basic with plans for improvement being very vague. In Choice of Home section the plane for improvement was stated as “Not Applicable”. The AQAA also stated that plans were in place to commence resident’s surveys but this has not been implemented. Residents and staff meetings are few-annually. Most policies and procedures for the efficient running of the home are in place. The Statement of Purpose, Service User Guide and Management of Service Users’ money Valuable and Financial Affairs were unavailable. Mandatory training records were seen and induction is in place. The shortfall in hygiene standards in the kitchen and laundry means the health, safety and welfare of residents are not promoted. Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 24 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 2 2 X 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 2 1 X 2 X Baytrees Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA22 Regulation 22 Requirement The registered person must ensure that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. The registered person must ensure that service users are safeguarded from financial abuse, through deliberate intent, negligence or ignorance, in accordance with written policy. The registered person must ensure by risk assessment that the safety of service users is not compromised by uncovered radiators, or the absence of radiators. The registered person must ensure the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. This includes specialist bed and pressure relieving equipment. DS0000024113.V347503.R01.S.doc Timescale for action 31/03/08 2 YA23 13(6) 16(2)(l) 29/02/08 3 YA24 13 (4) (a) (c) 31/03/08 4 YA29 16(2)(c) 31/03/08 Baytrees Nursing Home Version 5.2 Page 26 5 YA30 16 (2) (j) 6 YA30 16 (2) (j) The registered person must ensure that the kitchen is kept clean and hygienic and must consult with the Environmental Health Authority on current legislation. The registered person must ensure that the laundry floor is impermeable and that the walls are readily cleanable. Hand washing facilities must be prominently sited within the laundry. This is an amended requirement from the last inspection. 31/03/08 31/03/08 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 Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Nursing Home DS0000024113.V347503.R01.S.doc Version 5.2 Page 28 - 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!