Inspection on 26/10/05 for Bushbury Court Nursing Home

This inspection was carried out on 26th October 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bushbury Court Nursing Home 01/12/08

Bushbury Court Nursing Home 04/01/07

Bushbury Court Nursing Home 13/03/06

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 Unannounced Inspection 26th October 2005 09:45 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.V261475.R01.S.doc Version 5.0 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.V261475.R01.S.doc Version 5.0 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.V261475.R01.S.doc Version 5.0 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. 30th September 2004 Date of last inspection Brief Description of the Service: Bushbury Court is a care home providing nursing, accommodation and personal care up to 21 people with mental health problems over the age of 65 years, on a continuing care basis. There is one dedicated respite care facility. It is owned and staffed by Heantun Care Housing Association on behalf of the Primary Care Trust. The home is situated in the Bushbury area of Wolverhampton and is within easy walking distance of local shops, hairdressers, pubs, churches 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.V261475.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Wednesday 26th October 2005. The inspection included observing activity within the home, a tour of the premises, looking at records, speaking with staff and examination of staff files. The manager and staff on duty were welcoming and offered their fullest cooperation throughout the inspection It was considered that most of National Minimum Standards were met, the home provides a good service for people; consequently, on this occasion mainly those standards identified as “key” by CSCI have been inspected. What the service does well: What has improved since the last inspection? What they could do better: The frequency of supervision must be increased to meet the requirements of the national minimum standards for care homes. The process must be recorded and appropriately delegated to senior staff to complete. This is an outstanding requirement made at the inspection on 30th September 2004 Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 Page 6 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.V261475.R01.S.doc Version 5.0 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.V261475.R01.S.doc Version 5.0 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): 2&3 The home has satisfactory terms and conditions of residence for service users. There is a consistent assessment process in place to adequately inform the care planning process and provide staff with the information they need to satisfactorily meet residents’ needs. EVIDENCE: The home has a ‘Terms of residency’ document offering information of the service provision. All service users have a written contract/statement of terms and conditions with the home and at the point of admission. People moving into the home have their needs assessed before moving into the home. Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 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): 7 & 10 There is a clear care planning system in place, which provides staff with the information they require to meet residents’ needs. Staff are sensitive to the individual needs of each service user and meet these in a professional manner. EVIDENCE: Each service user has an individual care plan generated from the pre admission assessments. The manager explained that most service users are unable to fully contribute to the care planning system due to cognitive problems. The care plans are reviewed at least monthly to reflect changing needs and current objectives for all health, personal and social care. It the registered manager audits a sample of the care plans monthly to ensure that the process of re evaluation and review continues. Management reports are completed on a monthly basis and forwarded to the commission. Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 Page 10 There are written procedure regarding privacy this was confirmed by observations of routines on the day confirmed that service users are treated with dignity and respect. Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 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): 13 & 15 Opportunities are available to all service users that incorporate individuals being able to exercise choice in the lifestyle they lead. Service users are offered a varied, well balanced diet, which takes into account individual likes and dislikes along with seasonal changes. EVIDENCE: The registered manager explained that wherever relatives/representatives handle the financial affairs of service users. Staff assist service users to make choices of their every day life. The choice and quality of meals was good. A menu is in place and was seen to offer a varied and wholesome diet. A record is now kept for all food provided for service users and is in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory. Observation of the breakfast-time meal was seen to be relaxed and in pleasant surroundings. Staff were seen to offer assistance where required. possible Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 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 & 17 The home has a satisfactory complaints system and there is evidence that residents feel that their views are listened to and acted upon. Written procedures are in place for protecting service users from harm. EVIDENCE: The complaints procedure is detailed in the service user guide and on display in the reception area of the home. It was stated by the manager that there had been no formal or informal complaints to the home since the last inspection. Service users legal rights are protected and discussion with the manager demonstrated a clear understanding of her responsibilities under this standard. The manager was aware of advocacy services available to service users. Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The standard of the environment is good providing service users with a safe well-maintained environment to live in. EVIDENCE: During the home tour, the standard of cleanliness was satisfactory and all areas were well presented. Staff were observed to be adhering to infection control policies throughout the visit. The kitchen storage area has been moved on the advice of the environmental health officer and this will be completed shortly. The lounge area has a large screen television that can be easily viewed in the lounge. The internal garden area is well maintained and suitably equipped with tables and benches. Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 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): 29 Service users are protected by the Heantun’s robust recruitment procedures. The service ensures the right staff are employed to look after vulnerable people. EVIDENCE: The manager was able to demonstrate her knowledge regarding Heantun’s recruitment process. The procedure includes the completion of an application form, the taking up of references, CRB checks, and interview. New staff undertake an induction process and a probationary period before they are confirmed in post. Staff files are kept centrally with all relevant information kept on site. Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 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): 36 & 37 The frequency of supervision falls below the required standard the home continues to address this issue. The home has raised the standard of record keeping since the last inspection. EVIDENCE: All care staff must receive formal recorded supervision at least 6 times per year. Supervision must cover all aspects of practice, the philosophy of care in the home and career development needs. All other staff must be supervised as part of the normal management process on a continuous basis. The home’s records and individuals records are kept safe and in good order. Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 Page 16 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 3 X Bushbury Court Nursing Home DS0000017182.V261475.R01.S.doc Version 5.0 Page 17 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 OP36 Regulation 18(2) Requirement All care staff must receive formal recorded supervision at least 6 times per year Timescale for action 31/01/06 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.V261475.R01.S.doc Version 5.0 Page 18 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.V261475.R01.S.doc Version 5.0 Page 19 - 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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