Inspection on 27/04/04 for Bushell House

Care Home For Older PeopleBushells HouseMill Lane Goosnargh Preston Lancashire PR3 2BJAnnounced Inspection27th April 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Bushells House Address Mill Lane, Goosnargh, Preston, Lancashire, PR3 2BJ Email address Name of registered provider(s)/company (if applicable) The Trustees Of Bushell House Name of registered manager (if applicable) Mrs Susan Jones Type of registration Care Home No. of places registered (if applicable) 31 Tel No: 01772 865225 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (31) Registration number F090000433 Date first registered 19th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 17th March 2003 YES NO 30/05/03 If Yes refer to Part CBushells HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 327th April 2004 10:00 am Ms Susan Dale N/A/ N/A N/A N/A N/AID Code079361Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionBushells HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementBushells HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Bushells House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Bushells HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Bushells House is situated in the village of Goosnargh and provides personal care to a maximum of thirty-one service users of both sexes. The home was established in 1743 as a charitable trust by Dr. William Bushell to provide a home offering care and support to elderly people in the local area. The daily management of the home is overseen by a board of Trustees who meet on a regular basis to discuss the smooth running of the charity. They work closely with the staff at Bushell House and pay regular visits to inspect the premises and speak with service users to ensure that high standards are maintained at all times. The home is large, luxurious and set in a beautiful garden; there are numerous communal rooms such as the library and dining room, nearly all the individual rooms are large and very well appointed. All the bedrooms are for single occupancy and many of the rooms have en suite facilities.Bushells HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Bushells House was inspected against the National Minimum Standards for Older People. The inspection took place in April 2004 and involved examination of records, discussion with the registered persons, staff, service users and visitors to the home. Comment cards were provided to service users and their relatives/representatives. Throughout the report there are references to the `tracking process, this is a method whereby the inspector focuses on a small group of service users. All records relating to these people are inspected. Service users are invited to discuss their experiences of the home with the inspector; this is not to the exclusion of the other service users who were involved in various ways. Questionnaires returned from the relatives of service users made the following comments: I am more than satisfied with the standard of care my mother receives. There is a very pleasant and friendly feeling on entering Bushell House. And again, I am very happy with the level of care and have every confidence in the staff at Bushell House. Choice of Home (Standards 1-6) 4 standards were assessed and met. A statement of purpose and service users guide had been developed and been made available to service users and their representatives. Service users are visited prior to admission to the home to ensure that the home can meet their needs and a full assessment takes place. A new and comprehensive format for recording the assessment and formulating a care plan has been introduced. The home does not provide intermediate care Health and Personal Care (Standards 7-11) 5 standards were assessed and met. From the information gained as part of the tracking process and examination of the care plans it appeared that the home meets the needs of the service users. The care planning process has been strengthened and now provides a comprehensive care plan that covers both physical and emotional needs. Care plans examined met all requirements under the standard and had been reviewed once a month. Medication storage and procedures meet requirements and a pharmacist audits the medication on a regular basis. A questionnaire was received from a Senior District Nurse who made comments that were full of praise for the staff and the management of the home in general, she also stated: The staff show the care plans to the Primary Nurse (who regularly visits) and ask for constructive criticism and advice. They are selective with their admissions and sometimes involve our nurses in case conferences. Daily Life and Social Activities (Standards 12-15) 3 standards were assessed and met. Evidence gathered during the inspection indicated that the routines of the home were flexible and designed to meet the needs and choices of the service users. Visitors are made welcome at any time and are able to see service users in private. Three questionnaires were Bushells House Page 6 returned from relatives who confirmed that they are consulted with regard to the service users care needs and that they are able to see their relative in private. Complaints and Protection (Standards 16-18) 1 standard was assessed and met. The home has a complaints policy which, is accessible to service users, relatives and other visitors to the home; no complaints had been received by either the management of the home or the CSCI. Questionnaires returned from service users confirmed that they were aware of the procedure to follow in the event of a complaint. Environment (Standards 19-26) 2 standards were assessed and 1 had been met. All the rooms are spacious and meet the minimum space requirements, three additional rooms have been re-furbished in order to allow service users to be increased to the maximum number of service users allowed for registration. Work is on going with regard to radiator covers to provide safe surface temperatures. Lockable facilities within each bedroom have been gradually introduced and any service user who is self medicating has had one provided for the medication to be safely locked up. Staffing (Standards 27-30) 4 standards were assessed and 3 were met. At the time of the inspection there were adequate staff on duty and the staffing levels were in accordance with the guidance issued by the previous registering authority. Training is a high priority and each staff member has been issued with a Personal Development Plan, which records their achievements. Six staff have achieved NVQ Level 2 and more staff are being encouraged to attend training. Management and Administration (Standards 31-38) 1 standard was assessed and met. The registered owner has many years experience in Management and Care and is in the process of obtaining a qualification, at N.V.Q. level 4 in Management and Care.Bushells HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action The exposed pipe work and radiators are Ongoing required to be covered in order to provide low as per 1 13 OP25 temperature surfaces. Work is on-going and Action st due to be completed by the 1 June 2004 PlanAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard Plans should continue with regard to staff obtaining a qualification at N.V.Q. level 2 in order to meet the requirement for 50 of trained members of staff by 2005. Confirmation should be provided to the CSCI once the registered manager completes a level 4 N.V.Q. in management and care qualification required by 2005.1OP282OP31CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Bushells HouseMet (Yes / No) Page 8 Bushells HousePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The exposed pipe work and radiators are Ongoing required to be covered in order to provide low as per 1 13 OP25 temperature surfaces. Work is on-going and Action due to be completed by 1st June 2004 PlanRECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * Plans should continue with regard to staff obtaining a qualification at N.V.Q. level 2 in order to meet the requirement for 50 of trained members of staff by 2005. Confirmation should be provided to the CSCI once the registered manager completes a level 4 N.V.Q. in management and care qualification required by 2005.1OP282OP31Bushells HousePage 10 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Bushells HousePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NO YES YES YES NO NO NA YES YES YES NO YES YES YES YES YES YES YES YES 8 2 0 YES YES YES YES 16 0 27/04/04 10.00 5.0Bushells HousePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Bushells HousePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 299.00 To (£) 365.00Any charges for extrasNOIf yes, please state what the extras are: 3 Key findings/Evidence Standard met? The home has produced a Statement of Purpose and Service User Guide that provides information about the home and the services provided. The Statement of Purpose has been altered as required from the last inspection, to state that services are to be provided to persons over the age of sixty-five years.Bushells HousePage 14 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? The standard was not assessed at this inspectionStandard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? A full assessment is undertaken for new service users that covers all areas as listed under the standard. The service user files examined contained very detailed information and the assessment looked at physical as well as emotional needs as well as any risks connected with the environment and care requirements. Likes and dislikes in all aspects are taken into account; the details include a `Residents Preferred Activities Sheet and a list of personal possessions. The format being used to record the details is excellent; the inspector recommended that care staff should complete boxes and obtain signatures whenever possible from the service user. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Generally the service users who are assessed and take up residence within the home are fairly independent. Specialist equipment or services would be provided as necessary. A hospital bed is available as required and a portable loop system has been purchased for use by service users who are hard of hearing.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Information about a 4 week trial visit is contained within the Statement of Purpose and a very flexible approach is taken ensuring that prospective service users are familiar with the home prior to any decision to stay there on a permanent basis. Generally emergency admissions are not allowed but they would be allowed depending on the circumstances.Bushells HousePage 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not provide Intermediate CareBushells HousePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? A plan of care is drawn up following the initial assessment; the care plan is split into a Day Care Plan and a Night Care Plan and covers all aspects of health, personal and social care needs. Evidence was provided that service users are involved in the process of formulating the care plan; a sheet was seen to be kept within the service user files called the `Service User View of Care Needs and this is signed by the service user. Risk assessments were in evidence on the files including a `Room Risk Assessment completed on a service user who was prone to falling. A Key Worker system has been adopted; the care plan was seen to have been reviewed on a monthly basis. A questionnaire was returned from a Social Care Professional who made the following comment: The manager is always helpful when I have been placing a new resident and keeps me informed of any change of circumstances.Bushells HousePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 8 03 Key findings/Evidence Standard met? There was ample evidence on the files to show that the service users health is maintained and promoted at all times. Professional advice had been sought as appropriate. Service users confirmed that opportunities are provided for appropriate exercise and physical activity. Nutritional screening is undertaken on admission and a record of weight maintained. Service users confirmed that they are able to see a G.P.of their choice and a questionnaire returned from a Health Professional confirmed that they are able to see their patients in private and are asked to comment on the suitability of the care plans; they are also invited to Case Conferences on individual service users with complex needs. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The home has a suitable medication policy and procedure. There are no controlled drugs being used at the present time. Many of the service users are self-medicating and this is clearly marked on the records kept; the details are also recorded at the initial assessment. A lockable facility is available within the service users private accommodation for the storage of any medication. There was evidence that staff have received accredited training in the administration of medicine. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Evidence was provided from talking to service users and staff that privacy and dignity are respected at all times particularly with regard to personal care giving and that all staff use their preferred form of address. A Questionnaire returned for a health professional confirmed that medical examinations and treatment are provided within the service users own room as referred to previously in standard 8. Some of the service users have their own phone and service users spoken to confirmed that they receive their mail unopened.Bushells HousePage 18 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The home has a comprehensive policy on the care of someone who is dying and and the procedure to follow when a service user dies. Information is also contained within the Service Users Guide. The procedures are flexible and maintain the privacy and dignity of the individual concerned. There was evidence of the files of a new form that records the last wishes of service users.Bushells HousePage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Service users confirmed that various activities are provided by the home including flower arranging, outings and communion. Other recreational activities include, speakers from Alston Hall; themed social evenings; musical entertainers; and outings to the Goosnargh Flower Show and retail outlets. Information about any special events are circulated either verbally or placed on the notice board and contained within the Statement of Purpose and Service Users Guide. Meal times are flexible on request and are served either in the dining room or the service users own room. A questionnaire was returned from a service user with the following comment: I would like to say how happy I have been since I came to Bushells House. If the weather is poor we are allowed to use the long corridors for exercise. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Visitors spoken to confirmed that they are able to see service users at any reasonable time and are always made to feel welcome. Information about visiting the home is contained within the Statement of Purpose and Service User Guide. Local clergymen attend the home each week to provide communion.Bushells HousePage 20 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? All the service users or their relatives handle their own financial affairs. Service users spoken to confirm that they are able to bring their own personal possessions with them according to the space available, an inventory is taken of personal possessions, the inspector recommended that a signature is obtained from the service user when the inventory is completed. Information about the advocacy service is available for the benefit of service users who have no one acting on their behalf with regard to their personal affairs. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Bushells HousePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 3 Key findings/Evidence Standard met? The home does have an appropriate complaints procedure and staff and service users spoken to confirm that they are aware of the procedure. No complaints had been recorded since the last inspection. Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Bushells HousePage 22 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence The standard was not assessed at this inspection. Standard met? YES X 0Bushells HousePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Bushells HousePage 24 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Bushells HousePage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO YES 31 12 0 0 3 31 00 0 0 0Key findings/Evidence Standard met? All the bedrooms are spacious and meet the required space requirements.Bushells HousePage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? All the rooms have natural ventilation. The water temperature is stored at the correct temperature of 60 degrees to prevent the risk of Legionella. The radiators are in need of being covered in order to provide low temperature surfaces; on-going work to improve the facilities is underway and radiators are being covered gradually as part of the process; work should be completed by the 1st June 2004. Lighting within the home meets recognised standards and is domestic in character. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Bushells HousePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 0 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 3 24 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X0 16 43 Key findings/Evidence Standard met? The above information has been provided by the manager of the home, however the Department of Health Staffing Guidance is not required to be implemented at the present time. The staffing rotas were examined and found to meet the staffing levels agreed with previous Local Authority guidance.Bushells HousePage 28 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 6 37.5 2 Key findings/Evidence Standard met? There was evidence on the staff files of training undertaken and Certificates; Personal Development Files are held by the staff and they act as a Portfolio for Assessment with regard to N.V.Q. training. The manager is aware of the need for 50 of care staff to achieve N.V.Q. level 2 by 2005.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? The home has a recruitment policy that includes a job description. The Application Form has been changed to show relevant information necessary for each applicant. The manager of the home has devised a set of interview questions and an interview checklist, both of which are considered to be good recruitment practice. All appropriate checks have been carried out prior to staff being employed including two references and a Criminal Records Check (C.R.B.) All staff are employed in accordance with the code of conduct and practice set by the General Social Care Council. C.R.B. checks have been carried out on every member of staff. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Training is high priority for all staff and a room within the building has been dedicated to the training of staff. Personal Development files are kept by the staff and there was evidence within them of a comprehensive training programme including, First Aid; Fire Safety; Introduction to Management; Moving and Handling; Abuse; Measuring Vital Observations; Medication Management; Continence Care and numerous other training courses in line with National Training Organisations Training Targets. Staff confirmed that they are supported and encouraged to undertake training by their managers.Bushells HousePage 29 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The registered manager has considerable experience in both management and care provision. and is currently attending training in order to achieve a qualification at N.V.Q. level 4 in Management and Care that is due to be completed by July 2005. The registered manager is not responsible for any other care home. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Bushells HousePage 30 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence The standard was not assessed at this inspection. Standard met? 0 2 0 0Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Bushells HousePage 31 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? The standard was not assessed at this inspection.Bushells HousePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSignature Signature SignatureBushells HousePage 33 Public reports It should be noted that all CSCI inspection reports are public documents.Bushells HousePage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 27th April 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleBushells HousePage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by.......... N/A....., which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Bushells HousePage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Bushells HousePage 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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