Care Home: Bayith Rest Home Ltd

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What the care home does well The home welcomes people who will use the service and their families or representatives, to visit the home and look at the facilities of the home. The manager seeks information from external healthcare professionals as part of the assessment where necessary, to ensure that the home is able to meet assessed needs. People moving into the home are assured that the home that they are entering will meet their needs. For example, staff are trained and show perception and professionalism in the way they deliver care, which enables people who live at the home to feel safe and enjoy a varied and companionable way of life. Staff treat people who live at the home with respect; they share their companionship and give support sensitively. Detailed records were in place that gave care staff information that enabled them to provide the help that individuals need.Health care was promoted through the use of tools that assist with monitoring the nutritional needs of individuals when that was necessary. The home has also developed good working relationships with healthcare specialists. Daily routines in the home were flexible and people who use the service being encouraged to make choices for themselves and exercise personal autonomy as far as was reasonably possible. People who live at the home were positive about the food that the home provided and were pleased with the activities in which they could participate and the condition of the accommodation that they occupied. People at the home, relatives and staff had confidence in the effectiveness of the home`s manager. Systems and procedures in the home worked well including, dealing with complaints, quality monitoring, and health and safety. What has improved since the last inspection? The environment is being improved through a planned refurbishment programme with bedrooms have been redecorated and one bathroom having had a new bath with hoist fitted. What the care home could do better: There are no issues raised within the report from this visit. CARE HOMES FOR OLDER PEOPLE Bayith Rest Home Ltd 18/20 Bevan Road Lovedean Waterlooville Hampshire PO8 9QH Lead Inspector Val Sevier Unannounced Inspection 09:45 21 January 2008 st 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 Bayith Rest Home Ltd DS0000070057.V354418.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 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. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bayith Rest Home Ltd Address 18/20 Bevan Road Lovedean Waterlooville Hampshire PO8 9QH 02392 597388 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) janegiles@ntlworld.com Bayith Rest Home Ltd Ms Jane Catherine Giles Care Home 12 Category(ies) of Dementia (0), Mental disorder, excluding registration, with number learning disability or dementia (0), Old age, not of places falling within any other category (0) Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Mental disorder, excluding learning disability or dementia (MD) 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 12. Date of last inspection New service Brief Description of the Service: Bayith is a family run home in a residential area in Lovedean. It is close to a local bus service and shops. The service offered supports people with mental health or dementia. The home is currently undergoing refurbishment and redecoration with a new bath having been fitted upstairs and when this is commissioned the downstairs bathroom will be refurbished. The fees for the home are per week and are based on assessed need and range between £395 and £460. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service 2 star. This means the people that use this service experience good quality outcomes. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: the Annual Quality Assurance Assessment (AQAA) completed by the home, and an unannounced visit to the home, which was carried out on the 21st January 2008, during which we were able to have discussions with staff and have interaction with the residents at the home. During the visit we looked around the inside and outside of the home, which included a sample of bedrooms and bathrooms. Staff and care records were sampled and in addition to speaking with staff and residents, their day-to-day interaction was observed. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. What the service does well: The home welcomes people who will use the service and their families or representatives, to visit the home and look at the facilities of the home. The manager seeks information from external healthcare professionals as part of the assessment where necessary, to ensure that the home is able to meet assessed needs. People moving into the home are assured that the home that they are entering will meet their needs. For example, staff are trained and show perception and professionalism in the way they deliver care, which enables people who live at the home to feel safe and enjoy a varied and companionable way of life. Staff treat people who live at the home with respect; they share their companionship and give support sensitively. Detailed records were in place that gave care staff information that enabled them to provide the help that individuals need. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 6 Health care was promoted through the use of tools that assist with monitoring the nutritional needs of individuals when that was necessary. The home has also developed good working relationships with healthcare specialists. Daily routines in the home were flexible and people who use the service being encouraged to make choices for themselves and exercise personal autonomy as far as was reasonably possible. People who live at the home were positive about the food that the home provided and were pleased with the activities in which they could participate and the condition of the accommodation that they occupied. People at the home, relatives and staff had confidence in the effectiveness of the home’s manager. Systems and procedures in the home worked well including, dealing with complaints, quality monitoring, and health and safety. 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. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are considering using the service are given appropriate information about the service to enable them to make an informed choice. People that use the service can feel assured that their needs will be assessed and that the home has an understanding of their needs using the assessment process. EVIDENCE: The statement of purpose and service users guide is in the form of a brochure and contains information about the home and its facilities. The guide also comments on the values of the home, on privacy, dignity, independence, civil rights, choice, fulfilment, and ethnic and cultural diversity and security. We received the AQAA for the home which stated that: “All perspective residents are visited and a thorough assessment of there needs are assessed Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 9 by myself. If I feel that the information i have obtained from the client, relative and/or care manager, staff is insufficient for me to make a positive decision then I always contact the Registered G.P for his/her valued opinion regarding the appropiateness of placement at Bayith.” “When I assess residents i always look at there physical and health condition long term as i feel it would be unfair to accept a resident that would need to be moved again to a nursing home within a short time. This would be unfair and could have detrimental effects on the residents wellbeing. If I feel that Bayith is not appropriate for the perspective resident or if we would be unable to meet there care needs then i always give an honest explanation as to why.” (The manager) This was supported by evidence in the records at the home and with talking with relatives of individuals who had moved to the home in the last year. The assessment includes the following areas: personal hygiene and dressing; safe environment; eating and drinking and swallowing; working and leisure; sleeping and aids to ability. It was also noted that there was information gathered from others who are involved in caring and supporting the individual, including the family and other health professionals. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The records and systems within the home that ensure that the personal and healthcare needs of people who use the service are met safely and effectively. Staff working practice helped to ensure that the privacy and dignity of people who use the service is promoted. EVIDENCE: The manager stated in the AQAA returned to us that: “We provide a very high standard of personal care ensuring residents privacy, dignity and independence are maintained. Care plans are indepth and easy to understand. We involve our residents as much as possible in the review process and also their relatives. Care plans are reviewed monthly or sooner if necessary. They are readily available for access if the residents wish to see them. Residents have regular visits from their G.P and they are called upon Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 11 immediatley if requested or required to do so. We also have regular visits from the Opticians, Chiropodists, Continence Nurse and Community Psychiatric Nurses. District Nurses are also frequent visitors to Bayith, they are our main port of call, we work very closely with the nurses as they are the ones that can get the equipment for us if needed. Medication is stored, controlled and handled safely. I maintain daily checks on the medication especially the controlled drugs to maximise safe storage and to ensure correct procedures are being adhered too.” We sampled three care plans of people who use the service that had moved to the home in the last year. The care plans sampled were being used in conjunction with medication records and other health-monitoring tools that are used as part of the care planning for individuals. The care plans that have been developed for the residents were seen to be a working tool, with records of daily life and regular evaluations by the key worker. The documents seen and the plans were based on the assessments the home carried out in order to identify what help individuals needed. Assessments included a range of potential risks to residents e.g. pressure sores; falls; moving and handling; malnutrition; etc. Where a pressure sore assessment indicated that an individual was at risk it was noted that the corresponding plan of care for the person concerned referred to the use a pressure relieving aid. The district nurses support the home in the care of any areas at risk or that have broken down. We were able to see that pressure area breakdown had been present when an individual moved to the home and there were no incidents of areas having developed by people who had been at the home for some time. It was also noted that the care and treatment in support of pressure areas that had broken down had been successful. The plans examined set out clearly the actions and support staff needed to take and what specialist equipment was needed to provide the support and assistance each person required. For example where support with movement was identified instructions on numbers of staff needed, equipment and communication was seen. It was seen in the care plans that physical health needs are also addressed with recent residents having moved to the home with information from health and other specialists; this information has been incorporated into the care plan at this home. It was also seen that residents have access to opticians and dentists as needed. Notes regarding physical health indicated that other professionals had been involved as necessary for example regular visits from the community psychiatric nurses to assist the home in caring for the needs of those individuals with dementia. Records indicated that care plans were reviewed regularly and as needs changed and daily notes referred to the actions taken by staff to provide the Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 12 needs set out in those plans. Care plans are agreed with the person using the service where possible and their relative or representative. The home had written policies and procedures concerned with the management and administration of medication. Medication was kept in locked and secured medicine trolleys, cupboards and where required in a medical refrigerator. Controlled drugs were stored securely and appropriately. The home dispenses all medication from blister packs and the only staff in the home that dispensed and were responsible for the management and administration of medication on a day-to-day basis were trained staff. There has been an incident recently where medication prescribed to an individual at the home has gone missing. The manager has reported this to the police and us. It was seen at medication time in the afternoon that staff crushed medication for three individuals. This was discussed with the manager at the time as it was not clear in the medication records that agreement and discussion had taken place with relatives and the doctor about this. The manager stated that an assessment and agreement would be put into the individual’s records and reviewed each time medication was given. Staff were observed speaking and assisting the residents with dignity and respect. Affection was given appropriately to those residents who sought it. It had been seen on care plans that the preferred choice of name had been recorded and staff were heard to speak to residents by the name they wished. Which supported the statement in the AQAA from the home: “Staff are taken through the importance of privacy and respect during their induction. They are taught the simplist of tasks such as knocking on a residents door prior to entering, be friendly, polite and courteous but most importantly treat our residents how you would expect to be treated.” Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service participate in activities appropriate to their age, peer group and cultural beliefs as part of the local community. Dietary needs are well catered for with a balance and varied selection of food available that meets individual dietary requirements and choices. EVIDENCE: The lounge in the home has two televisions and it was noted that both televisions were on the same channel, enabling people in the room to see them. There were also areas in the lounge where people are able to sit quietly if they wish. It was observed that there were magazines and daily papers available for people to read, and individuals passed them to their neighbours as they finished them. People living at the home and visitors spoken with on the day said that there were televisions in individual’s bedrooms as well and they were able to watch them as the wished. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 14 The home offers an activities programme which includes games, crafts, College courses, walks to the local shops, trips to the local town and recently, Creative Memories, This is building a life history of the residents through photos and descriptions of their life and placing it in their personal album, this enables the staff to reminisce with them. We were able to see the workbooks that the local college provides for the twelve week courses that residents undertake. The college comes to the home - a tutor and two learning support workers who have a special interest and skill in working with people who have dementia and hearing difficulties. There are regular visits from the hairdresser and mobile library. There is monthly Holy Communion. The home operates an open visiting policy and maintains family ties, the home enables regular visits and has regular coffee mornings. All residents are encouraged to exercise control over their lives and it is their choice to participate in social activities if they wish. Visitors spoken with said that staff try to help the residents to maintain their rights and for them to be able to make informed choices around daily living. School children come in on specific term dates to spend time talking and playing games with the residents, they also help with letter writing which helps maintain contact with friends and family. All residents spoken who were able to pass comment were complimentary about the food provided. The meals seen looked nice and were presented in a way that looked appealing. The menus and records of food provided indicated that the food was nutritious and there was a wide range of meals provided with a selection of choices every day. In addition special diets and individual preferences and needs were catered for e.g. soft and pureed meals and diabetics. Residents could choose where to eat and some preferred to eat in their rooms. Food preferences, dislikes, food related allergies and nutritional and dietary requirements were recorded in residents care plans and the information was also readily available to catering staff. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are protected through the open complaints process and the staff’s knowledge and understanding of safeguarding and protection issues. EVIDENCE: The homes complaints procedure was seen to be available in the information given to people who use the service. There have been no complaints received by the home or the commission. The manager advised that the home promotes an open door approach to relatives and people who use the service, to help resolve complaints and issues effectively. The home uses Hampshire’s safeguarding adult policy and staff were seen to have training in adult protection as part of their induction as well as yearly updates. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have a pleasant and homely environment to live in which also has had adaptations to meet individual needs. EVIDENCE: The inspector looked around some of the home and was able to see communal areas such as the dining room, lounge, bedrooms and bathrooms. The garden is accessible with wheelchairs. All of the bedrooms seen were brightly decorated and had evidence of individual personalities with posters and the service users photographs on the walls, and other personal effects. People who live at the home are encouraged to furnish the room with personal belongings such as furniture and pictures, to make it feel like home. Consideration is given to the support of needs with the use of equipment. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 17 Specialist beds are available at the home for those that are assessed as needing them. There is also specialist seating, a lift and adapted bathing facilities. We looked around some of the home and were able to see communal areas such as the dining room, kitchen, bedrooms and bathrooms. There was redecoration and refurbishment taking place at the time of the visit and there is a plan for the whole home. One bathroom upstairs is nearing completion of its refurbishment with a new bath having been fitted, once this is completed the downstairs bathroom will be refurbished. It was noted that in accordance with best practice all communal WCs that were seen were provided with liquid soap dispensers (that were full and working), alcohol gel sanitizers and paper towels. Protective clothing was readily available and staff were observed using gloves and aprons appropriately. The home’s laundry was appropriately sited and equipped and effective procedures were in place for the management of soiled laundry items. The home manages all the laundry with dedicated staff. There was no malodour in the home and it was seen to be clean and tidy. Comments from residents about the condition of the premises included: • “They are particular about keeping it clean, the windows ands so on, I think they also look after the building”. • “It is kept spotless and I like looking out of the window. The trees and plants change colours and I can see the birds”. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services have their needs met by staff who are trained, supportive and sufficient in numbers. People who use the services are protected by the recruitment procedure. EVIDENCE: The staffing structure provides a broad spread of experience and professionalism: manager, care workers, kitchen staff, laundry and housekeeping. Other health care professionals support the team from outside the home as needed. Staff spoken with on the day of inspection indicated that they were aware of the needs of the residents who live at the home; they also seemed enthusiastic about working at the home. The rotas indicated that there were sufficient staff to meet the needs of the people at the home. There was evidence that staff have received training in all mandatory areas such as food hygiene, first aid and manual handling, health and safety, vulnerable adults, infection control, continence management, challenging behaviour and dementia. Staff receive at last three days training a year and are enabled to access courses either at the home or externally. New staff undertake two-day induction period when mandatory training is undertaken. This is followed by the induction pack, which is supervised by the Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 19 individual staff members mentor. The time taken to complete this induction pack, which is based on ‘Skills for Life’, depends on the individual member of staff but is usually twelve weeks. Modules covered are: values, understanding the organisation and the role of the worker, health and safety for example fire and incidents, communication for example call bells and methods of communication, abuse and neglect and developing as a worker. After each model there is an exam, which is marked by an outside agency. Staff are expected to pass the exams as part of the evidence of their knowledge and understanding of their role. All staff with the exception of the latest staff member, have completed at least the NVQ 2 in care. Records were examined of three staff that had been employed to work in the home since the last fieldwork visit to the home. Records indicated that statutorily required pre-employment checks, intended to ensure that people unsuitable to work with vulnerable adults were not employed, had been completed before the individuals concerned actually started working in the home. The manager explained that after interviewing, references are sent for and the CRB check is requested, a member of staff commences employment after the references are received and under supervision whilst waiting for the CRB check to be completed. The POVA First is included on this check and is returned before employment commences. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from a well run home; with systems and procedures in place which monitor and maintain the quality of the service provided and promotes the safety and welfare of everyone living and working in the home. EVIDENCE: The registered manager is Ms Giles who is the daughter of the owner. She is nearing completion of the registered managers award and completed a Supervision & Appraisals Course. Ms Giles has completed a Train the Trainer’s course in the Mental Capacity Act 2005 and also Dementia and recently enrolled on Business Management in Care Course. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 21 Ms Giles felt that she wanted to strengthen the management of the home and has promoted one of the care staff to deputy, who isqualified at NVQ 3 Level and has a very good working relationship with all the staff, residents and relatives. The manager is currently taking her through the management process so she is aware of all the standards and what is required. There is a clear Management structure with Policy & procedures reviewed annually. There were a range of written policies and procedures available for staff to refer to as guidance and to inform their practice. These included the following: • Admission, discharge and transfer of residents • Human Rights • Confidentiality and access to personal records • Abuse of the person • Drug administration • Self administration of medication • Infection control • Complaints procedure • Whistle-blowing • Sexuality • Health and safety at work The people who use the service and their relatives or representatives and the staff, are able to discus all aspects of the running of the home generally or on a personal level. This opportunity is offered in resident, relative and staff meetings, and in questionnaires, which are sent out annually. Resident’s monies & valuables can be locked in lockable drawers in the resident’s room or in a safe. Records are kept of everything kept in the safe. It was noted that the home’s equipment, plant and systems were checked and serviced or implemented at appropriate intervals for example hoists; fire safety equipment; portable electrical equipment and hot water system. There were contracts in place for the disposal of clinical and household waste. Records were kept of accidents and incidnets. There was a fire risk assessment for the premises; tests of equipment and regular risk assessments of the premises and working practices were undertaken regularly. Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 22 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South East Region The Oast Hermitage Court Hermitage Lane Maidstone Kent 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 Bayith Rest Home Ltd DS0000070057.V354418.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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