Inspection on 04/01/07 for Bushbury Court Nursing Home

This inspection was carried out on 4th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 13/03/06

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 Mr Ian Harris Key Unannounced Inspection 4th January 2007 08:00 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.V297377.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. Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 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.V297377.R01.S.doc Version 5.2 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. 13th March 2006 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. The current fees range from £411-60 to £418 per week Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 5 hours in the presence of the Manager. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked and the last reports of the Fire Prevention Officer and Environmental Health Officer were considered. 3 members of staff 6 residents were spoken to. What the service does well: What has improved since the last inspection? The home has a programme of maintenance and refurbishment and since the last inspection the kitchen has been redecorated a stored room created and 4 Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 6 new special nursing beds have been provided, all the mattresses have been replaced, a new hoist and Pan washer has been purchased. The staff files have been greatly 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. Bushbury Court Nursing Home DS0000017182.V297377.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 Bushbury Court Nursing Home DS0000017182.V297377.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): 3 and 6 The quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory admissions procedure ensuring the individual needs of the residents are fully met. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. EVIDENCE: All the residents are referred by the P.C.T. and undergo a full multi-disciplinary assessment prior to admission. Copies of the assessment, Care Plan and Reviews are on the residents’ files. The Six residents files and care plans inspected contained pre admission assessments of the persons needs, both from assessments by the home’s staff and other relevant professionals. Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 9 Observations and discussions with the Care Manager and staff on duty indicated that the home continues to meet the individual needs of the elderly people living at the home in a satisfactory and sensitive manner. Bushbury Court Nursing Home DS0000017182.V297377.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, the quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. Each resident has a individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements being in place to ensure resident’s medication needs are met. EVIDENCE: The home provides a Care Plan for each individual resident based on the initial assessment. Where possible the Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 11 to show the care Plans are being carried out and reviewed on a monthly basis. It was evident during the inspection, from looking at records, inspecting the facilities, observation of care given and chatting to staff and residents that individual health, and personal needs were being met. Residents were being treated with respect, and staff were working sensitively in meeting individual needs. All the residents looked comfortable and well cared for. The case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The residents’ health is closely monitored and appropriate medical care services are sought as and when required. The Inspector spoke to several service users, but was unable to have meaningful conversation. The residents appeared to be content, comfortable and happy. The residents medication is administered by trained nursing staff and the system appears to be working very well. The home receives good support from the pharmacist. All Senior Staff have been trained to use the system before they are allowed to administer medication and have completed the Safe Handling of Medication training course. The home has good policies and procedures, regarding the administration, storage and recording of medication. Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 12 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, and 15 the quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The home provides a good programme of social activities within the home and outside the home, which are designed to meet the resident’s capabilities, which, the staff encourage residents to pursue. The Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The meals in the home are good offering both choice and variety and also catering for special dietary needs. EVIDENCE: The Home works hard to involve residents in a range of leisure opportunities, consistent with each resident’s capabilities, which is very limited. The role of the activity organiser ensures there are a variety of things for residents to do as a group or on their own. It was noted that the people who currently live at Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 13 the home have enjoyed numerous outings throughout the summer and a number of resident went on holiday to Wales. It was noted that the home does not have a budget for social and leisure activities, outings and holidays. These are paid for mainly by the fund raising activities of the staff at the home. Although this activity is to be commended the home should be provided with a budget to easy the pressure on staff to raise money. The Registered Manager stated that the residents’ are positively assisted and helped to exercise choice and control over their lives. A close liaison is maintained with the relatives and representatives, where the service users are not able to make certain decisions. All residents’ appeared to enjoy the standard and choice of food provided. It was apparent that the menu is changed to incorporate seasonal changes and residents relatives are consulted regarding likes and dislikes of their relatives. Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 14 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 and 18 the quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure and there is evidence that residents’ and their families feel that their views are listened to and acted upon The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. EVIDENCE: The home has a good comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide, which a copy is placed in the reception hall. The home has a complaints book in which all complaints are recorded. It was noted that the home has not received any formal complaints since the last inspection all minor complaints are dealt with appropriately and quickly. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which, includes a WhistleBlowing policy. These issues are also covered in external and N.V.Q. training, which all care Staff have undergone. Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 15 Bushbury Court Nursing Home DS0000017182.V297377.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 and 26 the quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home and the garden is good providing the residents with a very attractive, comfortable, homely and safe place to live. The home was found to be clean tidy and free of unpleasant odour. EVIDENCE: The home has been established for a number of years and is maintained to a good standard, as is the gardens and grounds and provides a very comfortable homely and safe environment. It was noted that a number of bedrooms are very dark partly due to the colour of the wall covering. Also the clinic is in need of redecoration. A programme of refurbishment and redecoration of the Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 17 bedrooms should commence. It was noted that all the bedrooms have been personalised with the resident’s own personal possessions. This gives the appearance of a comfortable environment. The home offers good facilities and communal space. There is a choice of lounge/ sitting areas within the home that are decorated and furnished to a good standard. All the shared spaces within the home provide a warm, friendly, safe and comfortable environment. It is recommended that the bathroom that is little used. Is converted into a walk in shower room. This would benefit the residents and provide them with a choice of a bathroom or shower room. The home has very good hygiene and infection control policies and all the care and catering staff have undergone Food Hygiene and infection control training. All the staff are conscious of the risks of cross infection. Bushbury Court Nursing Home DS0000017182.V297377.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, and 30 the quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The The The The home is staffed with adequate numbers and skill mix of staff. staff have a very good understanding of the residents support needs. home has good policies and procedures regarding the recruitment of staff. home has a very good staff-training programme. EVIDENCE: The inspection of staff rotas and discussions with staff and residents indicated that the home is adequately staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. It was noted that there have been minimal staff changes since the last inspection. The home operates an efficient recruitment procedure. On inspecting 6 staff files, there was evidence within them that all C.R.B. checks are being carried out. All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has a programme of N.V.Q. training has exceeded the minimum standard. Also the care staff have attended Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 19 courses on Safe handling of medication, Dementia care, Moving and handling, Risk assessment, Record keeping, First Aid and Health and safety at work. Bushbury Court Nursing Home DS0000017182.V297377.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 and 38 The quality in these outcome areas is good. This judgement has been made using available evidence including a visit to this service This judgement has been made using available evidence including a visit to this service. The home is well managed by a competent registered manager, where service users interests and welfare is promoted. The home has good policies and procedures regarding Health and safety and meets the requirements of the Fire Officer and Environmental Health Officer, promoting EVIDENCE: Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 21 The home is well managed by the Care Manager who is qualified in both practice and management and has considerable experience in caring for older people in residential homes There are clear lines of accountability within the home and the manager is very supportive of both staff and residents. Observations made and discussions with residents’ and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residents who could express themselves stated that they are happy to approach the Care Manager and staff with any problems they might have and were confident that they would be responded to. There is a good staff supervision system in place and there is evidence that the staff have regular supervision meetings. It was also noted that the home has a Quality Assurance system in place, which includes questionnaires to residents, visitors and relatives to obtain feedback on the quality of service. However consultation only takes place annually. Consultation should take place at least twice a year. The feedback from the last issue of questionnaires was very positive with all feedback stating they are satisfied with the care they are receiving. The routines and activities within the home are flexible and built around the needs of the residents. There was also evidence to show that staff consult with the residents where possible and relatives regarding the choice of meals and activities. All the records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All recommendations and requirements made at the last inspections of the Fire Prevention Officer and Environmental Health Officer have been actioned. All safety equipment is regularly checked and well maintained. Bushbury Court Nursing Home DS0000017182.V297377.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 X X 3 X X 3 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 2 X X X X X X 3 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 Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement Timescale for action 01/04/07 2 OP33 24 (1) 3 OP19 23 The registered person Must ensure that a rolling programme of redecoration and refurbishment of the bedrooms takes place The registered manager must 01/02/07 ensure that consultation questionnaires are issued at least twice a year as part of the homes quality assurance system. The registered person 01/04/07 Must ensure that the clinic is redecorated and refurbished. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP12 OP19 Good Practice Recommendations The registered person considers the provision of a budget for social and leisure activities. The registered person considers the provision of a walking shower room. Bushbury Court Nursing Home DS0000017182.V297377.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Bushbury Court Nursing Home DS0000017182.V297377.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. 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