Inspection on 13/03/06 for Bushbury Court Nursing Home

This inspection was carried out on 13th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Bushbury Court Nursing Home 01/12/08

Bushbury Court Nursing Home 04/01/07

Bushbury Court Nursing Home 26/10/05

Bushbury Court Nursing Home 30/09/04

Bushbury Court Nursing Home 10/05/04

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

CARE HOMES FOR OLDER PEOPLE Bushbury Court Nursing Home Hellier Road Bushbury Wolverhampton West Midlands WV10 8EE Lead Inspector Philip Farmer Announced Inspection 13th March 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bushbury Court Nursing Home Address Hellier Road Bushbury Wolverhampton West Midlands WV10 8EE 01902 444066 01902 444065 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) Heantun Care Housing Association Limited Mrs Barbara Smith Care Home 21 Category(ies) of Dementia (21) registration, with number of places Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 (three) people under the age of 65 years may be admitted to the home on the condition that they fully meet the assessment criteria or who have early onset dementia. 26th October 2005 Date of last inspection Brief Description of the Service: Bushbury Court is a care home providing nursing care for up to 21 people with mental health problems usually over the age of 65 years, on a continuing care basis. It is owned by the Primary Care Trust (PCT) and Managed by Heantun Care Housing Association on their behalf. The home is situated in the Bushbury area north Wolverhampton and is within easy walking distance of local shops, which includes a Library, hairdressers, pub, church and doctors surgery. The home consists of a single storey purpose built building. Twelve of the bedrooms are single occupancy and four twin rooms. The communal areas are spacious and homely. There is ample care parking at the front of the building, and an enclosed rear garden. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over 3 hours on Monday 13th March 2006. This inspection was announced at short notice to the home, the pre inspection questionnaire was returned as agreed at the inspection. Staff, service user and relative questionnaires were distributed but none were returned at the point of writing this report. The inspection included observing activity within the home, a tour of the premises, looking at records, and staff and service user files along with care plans were inspected, together with supporting documents. The manager, three care staff and a registered nurse were on the premises at the time of the inspection; they were welcoming and offered their fullest cooperation throughout the inspection. 11 people are currently living at the home; this is below capacity and the service is currently under review by the PCT with a view to broadening the range of service users it may accommodate. On this occasion a total of 12 out of 38 National Minimum Standards were assessed. The other standards considered to be key were assessed at the inspection on 26th October 2005. Most of the National Minimum Standards were met; the home provides a good service for people; consequently, on this occasion only those standards identified as “key” by CSCI have been inspected. What the service does well: What has improved since the last inspection? Staff supervision has greatly improved since the last inspection and this must be maintained. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 6 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. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 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 Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards not assessed on this occasion see report dated 26th October 2005. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8&9 The staff are sensitive to the individual health needs of each service user and meet these in a professional manner. Health care needs are met and the medication was well managed promoting good health. EVIDENCE: The health care needs of people who live at Bushbury Court are fully met. The Manager stated that GPs and consultants visit the home on a daily/weekly basis; this was supported from notes in the records. The surgery for most service users is located next door to the home. District nurses Doctors, chiropodists and opticians visit the home and this process is recorded. All other specialist health care services are accessed when the need arises; health care needs are reviewed monthly. The home operates a 28-day cycle of medication administration in the bottle and box system. The medication administration records are completed each time. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 10 The medicines within the home, the Medication Administration Records and the Controlled Drug Register were examined and found to be accurate, authorised appropriately and drugs were stored safely. A list of specimen signatures to enable staff identification when administering medication was held on the file. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 14 There was a range of social, religious and recreational opportunities available to meet the expectations of the service users who live at Bushbury Court home. Visitors were welcomed in an open and friendly manner and service users were supported and encouraged to maintain contact with family and friends and to make their own choices about their day-to-day lives. EVIDENCE: Formally social activities are arranged throughout the year, this has included outings using community transport and events undertaken on a one to one basis. Generally activities are arranged on a daily basis to suit the needs of service users on that particular day. During the inspection, staff were observed welcoming relatives and friends of the service users and Manager confirmed that there was open visiting for family and friends. The registered manager explained that wherever possible relatives and representatives handle the financial affairs of service users. Staff assist service users to make choices of their every day life. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Concerns and complaints are dealt with promptly and professionally and procedures and practices are in place to ensure that individuals are protected from abuse. Service users are protected from abuse by the home’s Adult Protection procedures regular training in Adult Protection and Abuse Awareness takes place. EVIDENCE: There had been no complaints made to the home since the last inspection and none had been made to CSCI. There was a complaints procedure on site and this was issued to the residents in the service user guide, complainants are aware they can lodge a complaint with CSCI at any time. No incidents of neglect or abuse of any kind has been reported. The policy documentation was seen, the manager confirmed that residents are protected from all forms of abuse. At the time of this inspection all staff had received training in adult protection issues and this included how to report any issues. There were appropriate policies and procedures on site and also a copy of the updated multi agency guidelines for adult protection. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home was very clean throughout and contributed to the overall control of infection. EVIDENCE: At the time of the inspection the home was clean, pleasant and hygienic. Laundry facilities were found to be well organised, clean and hygienic. Foul laundry was washed at the appropriate temperatures to ensure it was thoroughly clean and to control the risk of infection. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 & 30 Staffing numbers and the skill mix was appropriate to meet the assessed needs of the service users. A thorough recruitment and selection procedure was in place and ensured the continued protection of the service users. Some improvement is required in relation to the keeping of CRB records at the home. EVIDENCE: At the time of the inspection, there were 11 service users accommodated at the home, all with continuing care needs. The recruitment and selection procedures within the home were good with exception of some CRB information. Minor improvement to CRB records in relation to recording the protection of Vulnerable adults status of individual staff members is required. Three staff files were examined and each contained an application form, a record of CRB clearances, but not in sufficient detail in relation to POVA clearances. Two references and details of qualifications and training proofs of identity were also held on each file including a recent photograph of the individual member of staff, all other information was well-documented and showed a thorough approach to ensuring the protection of those living within the home. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35 & 38 There was a good atmosphere within the home and the home is run in the best interests of the people who live there. Records were stored safely, kept up to date and accurate to safeguard the rights of the residents. EVIDENCE: The care manager is a first level nurse and has the skills, experience and qualifications to manage the home on a day-to-day basis. She is currently waiting for the outcome of her registered managers award. The manager confirmed that further training has been accessed to update knowledge, skills and competence. Relatives and representatives are encouraged to handle financial matters on behalf of service users. The home operates a petty cash system for sundry expenditure with the head office issuing invoices for receipt of payments. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 16 Systems are in place for promoting and protecting the health, safety and welfare of service users and staff The manager was a competent and experienced person who, with her staff, had developed an open and positive approach creating a relaxed and inclusive atmosphere within the home. This running of the home was supported by robust procedures and policies, developed and communicated to staff. Staff meetings took place to enable staff to contribute to the way in which the service was delivered and feedback was actively sought from residents via an annual questionnaire, which was sent out each year. Records showed that views were taken into account and used accordingly. Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19,33. Timescale for action CRB information relating to POVA 30/04/06 checks must be kept on staff files Requirement 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 Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bushbury Court Nursing Home DS0000017182.V275810.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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