Inspection on 10/10/06 for Bushmere EPH

This inspection was carried out on 10th October 2006.

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

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

Other inspections for this house

Bushmere EPH 03/01/08

Bushmere EPH 13/12/05

Bushmere EPH 26/07/05

Bushmere EPH 15/02/05

Bushmere EPH 25/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bushmere EPH 137 Edenbridge Road Hall Green Birmingham B29 2AU Lead Inspector Kath Strong Unannounced Inspection 10th October 2006 09:40 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 Bushmere EPH DS0000033446.V316027.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. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bushmere EPH Address 137 Edenbridge Road Hall Green Birmingham B29 2AU 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) 0121 777 8308 0121 777 3714 Birmingham City Council (S) Mrs Rita Bridgit Gardner Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home is registered to accommodate 35 adults over 65 years who are in need of care for reasons of old age and may include mild dementia Registration category will be 35(OP) Minimum staffing levels are maintained at 5 care assistants plus a senior member of staff throughout the waking day of 14.5 hours Additionally to the above minimum staff levels there should also be 2 waking night care staff plus a senior on waking or sleeping-in duty Care/shift manager hours and ancillary staff should be provided in addition to care staff 13th December 2005 Date of last inspection Brief Description of the Service: Bushmere House is a large, purpose built, 35 bedded home for older people who may have mild dementia, which is owned and managed by the Local Authority. The home offers accommodation to 31 long stay residents, 2 respite care and 2 interim care residents who require residential care with a variety of needs and dependency. Bushmere is situated in a residential area of Hall Green/Fox Hollies and is close to local shops and amenities. It is a three-storey building, which offers single bedroom accommodation on each floor. There is a large enclosed garden to the rear of the building and adequate off road car parking to the front. The ground floor, known as Coronation Unit also houses a large dining room, lounge, a small smoking room, the main kitchen, laundry and medical room. The manager’s office is also situated on the ground floor. On each of the other units, Hollyhocks Unit, 1st floor and Emmerdale Unit, 2nd floor there is a lounge, dining room and kitchenette. Residents who are able to mobilise easily may be accommodated on the second floor. Assisted bathing, showering and toilet facilities are located on each floor to ensure choices and ease of access for residents. The home has a range of equipment to assist residents who have restricted mobility and the home accommodates wheelchair users. Each bedroom is supplied with a copy of the service user guide and other information relevant to the services provided by the home. The notice board Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 5 located in reception provides a wealth of information and copies of inspection reports for residents and visitors to access. The fee for permanent placements is £472.00 per week. Short stay is either £64.65 or £136.00 per week dependent on personal savings. Services not included in the fee rate hairdressing, chiropody, dry cleaning, dental care, optician and toiletries. The prices for these services vary depending on the level of input/care. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork visit was carried out over a period of eight hours; assistance was provided by the registered manager throughout. There were 31 residents living at the home on the day of the visit. Information was gathered from speaking with residents, relatives and staff including two staff interviews. Care, health and safety and the arrangements for medications were inspected. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was carried out. Due to some residents having dementia it was at times not possible to hold meaningful discussions with them. Further information was provided from the pre-inspection questionnaire that was forwarded to CSCI prior to the fieldwork visit. Seven comment cards from residents and two from external professionals were also received prior to the visit being undertaken. Some post fieldwork was also carried out. At the conclusion verbal feedback was given to the registered manager. No immediate requirements were made. What the service does well: Residents reported their overall satisfaction with the standard of accommodation and the care provided. A comment received from a resident was, “It’s a good home”. Observations confirmed that the registered manager and assistant managers operate an ‘open door’ approach for residents and visitors. Discussions heard were transparent, friendly and helpful with appropriate advice given. There is a good mechanism for the safekeeping and financial transactions of monies held on behalf of residents ensuring that they are protected from the risk of financial abuse. Adequate and consistent staffing levels are maintained and the lack of use of agency staff promotes continuity of care for residents. There is a qualified ‘First Aider’ on duty for every shift who is able to give appropriate assistance and instigate action to be taken if a resident has an accident resulting in injury. Residents meetings are held regularly and this enables them to voice any concerns and to express opinions about how the home is run. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 7 The staff actively encourage and support residents in maintaining their independence and there are a good range of activities and outings offered to residents to promote their quality of life. The registered manager makes ongoing changes and introduces initiatives in the home and care plans to continually improve the services provided to residents. On some occasions the staffing numbers during daytime hours exceeds the minimum requirement. This helps staff in meeting all specific needs and in a timely fashion to suit the residents. What has improved since the last inspection? What they could do better: The practice of a member of staff signing MAR (medication administration record) charts prior to the medication being offered to residents must cease. This was brought to the attention of the registered manager in order to ensure that the health of residents is being promoted. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 8 The planned staff training of Health and Safety and Moving and Handling refresher courses need to be completed by all care staff. Completion of this will provide staff with the knowledge and needs to carry out their roles effectively. 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. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 9 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 Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose does not provide prospective residents or professionals with sufficient written details for them to make an informed decision about living at the home. Contracts of terms of residency do not supply adequate information about resident’s rights whilst living at the home. The home gathers pre-admission information from various sources to ensure that it is able to meet the individuals identified needs. EVIDENCE: The statement of purpose does not include the details about the two respite and two interim care beds that are available. The document will require further development to reflect the recently completed training of the registered manager for prospective residents to have comprehensive details about the services provided. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 11 The service user guide, which is located in each bedroom, supplies comprehensive details about the home. The file contains a good amount of other information some of which relates to the residents rights. This is viewed as being good practice. Those residents who are partially sighted would benefit from information being provided in large print or audio cassette. All residents are issued with a contract detailing the terms of residency. It was noted that the document fails to include the fee rate, services not included in the fee rate or details of the room occupied. The home is not providing residents with sufficient information about their rights. Although pre-admission assessments are carried out by a social worker the home has developed its own tool that is used when prospective residents visit the home. The tool also includes a section to record likes/dislikes. The arrangements serve to ensure that the home is able to meet the respective persons needs at the time of admission . Advice was given that if a resident is admitted to hospital staff may go to the hospital to re-assess the new needs to determine if the home is still able to meet those needs. The home is commended for this initiative. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In practice resident’s healthcare needs are well met but this is not always evidenced in the care planning. Staff practices in respect of safe administration of medications need to be improved to ensure that residents receive their medications safely. Observations of staff indicated that resident’s privacy and dignity are being maintained. EVIDENCE: Each resident has a written care plan. This identifies the assessments carried out and the care needs that staff should deliver to promote the resident’s health and well being. The home uses documents issued by the Local Authority for the development of care plans. The registered manager acknowledges that they are not robust enough and has introduced other forms to complement them. Examination of four care plans indicated that on the whole the system works well and there were some instances where very detailed information had been recorded. Where there were concerns about a resident, action plans had been developed to improve the health status of individuals. The inspector was impressed with the depth of some recordings. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 13 Relevant risk and nutritional assessments have been carried out and along with care plans were being regularly reviewed. There was ample evidence of external professionals being invited to attend to assess residents and provide staff with instructions to follow to restore residents to good health as far as practically possible. A carer was observed assisting a resident to the toilet and giving slow, clear and comprehensive instructions to encourage the resident’s independence and safety. Some improvements were needed to provide a complete picture of individual’s needs and action to be taken by staff: • More details regarding personal preferences should be recorded such as personal hygiene • The likely triggers and type of behaviour displayed should be recorded to compliment the staff instruction on how to deal with difficult to manage behaviour • Information about the persons life history and background may be useful in identifying why a reason for a residents behaviour • Short term care plans need to be developed for such conditions as urinary or chest infections. Positive feedback was provided by some residents, “On the whole the home is very good, staff are friendly and co-operative, it’s a good home”. A relative said, It’s a great home, I help out in the afternoons by handing out biscuits”. The system for the receiving, storage and disposal of medications were found to be good. Medications received from the pharmacist were being audited and the results documented to assess the accuracy before administration of the supply to residents commenced. Hand written medications had been signed by two persons to confirm that the instructions were correct. The resident who self medicates had been appropriately assessed as being competent and staff carry out regular checks to ensure the safety of the individual is being maintained. Administration of medications at lunchtime in the main dining room was observed. It was noted that without exception that the MAR (medication administration record) chart was being signed before the medication was offered to each resident. This is viewed as not being safe practice and was brought to the attention of the registered manager. The home must ensure that the management of medications safeguards residents from potential harm. Staff were observed using the preferred term of address towards residents. Personal care was delivered in the privacy of the resident’s own bedroom or a bathroom to preserve their dignity. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides varied social activities and outings that meet the expectations of residents providing them with interest and pleasure to improve the quality of their lives. Residents are able to exercise choices over their daily routines and staff encourages and promotes individuality and independence. A wholesome and varied diet is offered and specialist dietary needs are catered for. EVIDENCE: The programme of in-house activities and outings are tailored to individuals’ preferences. These include regular sessions of movement to music, bingo, church services and numerous other activities. Festivities are celebrated with a party and an external entertainer provides ‘old time music’ entertainment. In some cases a risk assessment has been carried out where the potential for an accident has been identified. A newsletter is regularly developed and fund raising activities are ongoing to contribute towards outings. Trips out include shopping and days out to such places as Weston Super Mare. A resident regularly attends a day centre. Records are maintained of those residents who have participated in activities to assist staff in identifying individual’s preferences. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 15 Comments received from residents included, I use the ring and ride and go to the club, I went out shopping, there’s two shopping parades within walking distance”. A resident was due to go on holiday the following week for five days. There was ample evidence that residents are supported in maintaining their independence and make decisions about how they wish to live. The home arranges an advocacy service for residents who would like a representative to express opinions on their behalf. A comment received was, “I tidy my own room, help to make my bed and dust round”. Another resident was being supported in her request to be moved to sheltered accommodation, a trial period was being organised. A resident entered the main office and senior staff spent a considerable amount of time talking with her. The agenda item of the regular residents meetings include, staffing, CSCI inspections, meals and activities and planned day trips. The minutes indicate that residents make choices and express their opinions about the day to day running of the home. A four week rolling menu is operated that provides residents with choices and encourages a healthy, well balanced nutritional diet is offered. Lunch was observed being served. The dining rooms were able to accommodate wheelchair users and the menu on display in the main dining room was in large print for the convenience of those persons who are visually impaired. The dining rooms on each floor were nicely prepared and residents are free to have their meals in any of those rooms or their own bedroom. The meals are served from hot trolleys, were well presented and good sized portions were served. A carer was observed gently encouraging a resident to sample the meal and offered alternatives to a resident who had refused the main course. Soft diets and pureed meals were appropriately served and assistance provided by carers ensured that residents were able to enjoy the individual tastes and textures of the meal. Staff were found to be observant and anticipated the needs of some residents without the need to make a request. Residents were noted to be conversing and using the opportunity to enjoy the meal. Comments received afterwards were, “Some of the meals I really enjoy, you get two choices”. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives are confident that their views will be listened to and any complaints dealt with effectively. Lack of staff training in adult protection fails to protect residents from the risk of abuse. EVIDENCE: The complaints leaflet given to residents includes clear information on how to make a complaint and how it will be dealt with. Production of the procedure in large print and/or audiocassette will assist those persons who are visually impaired. The homes file was examined, it was determined that the home carries out investigations and takes appropriate action to resolve concerns that are raised. No complaints have been received by the home or CSCI since the previous inspection. The home uses the Birmingham multi agency adult protection procedure for guidance on how to respond to allegations of abuse. A recent allegation made by a resident confirmed that the home responds correctly to concerns raised. Not all staff have received training in this aspect of care and during interview of two carers they were unable to demonstrate sufficient knowledge in respect of their role when abuse is alleged or suspected. The home must ensure that staff are provided with the knowledge and skills to act appropriately in protecting residents from the risk of abuse. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 17 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, 20, 21, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a warm, comfortable, safe, hygienic and well maintained home. The communal rooms and garden offer a good range of choices for residents. EVIDENCE: The building is purpose built for residential care and is cleaned to a high standard to protect residents from the risk of cross infection. Each floor has its own unit, which consist of lounge, dining room with kitchen off. Residents are encouraged to access all floors to socialise with other residents. A resident whose bedroom is on the ground floor was observed going up to the second floor in the shaft lift. Residents were noted to be wandering into the dining room between meal times. There is also a light, airy reception area where people can sit and access the large supply of written information. The smoking room, senior staff office and the main dining room Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 18 are located on the ground floor. The hairdressing salon is situated on the second floor and has god facilities for residents’ comfort. There is also an enclosed garden with seating for residents and visitors to frequent. Two bathrooms have been converted to shower and toilet. This now provides residents on all floors with choices about how they would like to bathe and the additional toilets are spacious to improve access for those persons who have restricted mobility. Bedrooms are of single occupancy, are individually and naturally ventilated, and windows are fitted with restrictors to prevent accidents occurring. The rooms of those residents whose care plans were reviewed were visited. The inspector was invited into a resident’s room, which was noted to be extremely personalised and contained an abundance of the residents own furniture. Residents are offered a door key to promote their preferences regarding privacy and dignity. The laundry and kitchen rooms were visited. They were found to be tidy and well organised and that procedures carried out to protect residents from the risk of infection. The sluice room on each floor had a coded door lock to protect residents from access and harm of COSHH items. Staff wore protective equipment to ensure lack of cross infection. Hot water outlets have thermostatic valves fitted to control the temperature of hot water. Those accessible by residents are regularly tested by running for two minutes and the results are recorded. This is carried out to protect residents from the risk of scalds. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are maintained in sufficient numbers ensuring that resident’s needs are being met. Recruitment practices are robust and protect residents from the risk of harm. Some staff training is needed to ensure that staff are supplied with the knowledge and skills to carry out their roles effectively. EVIDENCE: On some occasions the numbers of care staff allocated to daytime hours are in excess of the conditions of registration, this ensures that resident’s needs are being met. In addition the home has a full complement of housekeeping, laundry and kitchen staff to enable care staff to carry out their designated roles. Residents made comments of appreciation to staff included, “Thank you darling, you are a treasure”. Checking of staff personnel files indicated that all necessary checks are carried out and references sought before an applicant is offered a position. This indicates that resident’s safety is paramount. Newly appointed care staff undergo the homes own induction followed by a comprehensive formal induction to provide them with the skills to perform their roles appropriately. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 20 The staff training matrix determined that all care staff are required to complete a course in Health and Safety and refresher training in Moving and Handling. As discussed earlier in this report some staff need to attend training on Prevention of Abuse. The pre-inspection questionnaire indicated that 52 of staff have successfully completed training in NVQ level 2 to enhance their skills for the benefit of residents. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 21 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and possesses the skills to oversee the day to day management of the home. The quality assurance programme needs to be further developed to evidence that sustained improvements are ongoing process. Arrangements in respect of health and safety are robust and prevent residents from injury. EVIDENCE: The registered manager is experienced and is keen to make continuing improvements for the benefit of residents. She displayed a transparent approach to residents, visitors and staff and delegated tasks in a constructive manner. Discussions with staff revealed that they are well supported by the current management structure. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 22 Regular unannounced checks are carried out, reports developed and maintained within the home. This ensures an impartial opinion of the home is provided to assist the registered manager in making improvements to the services provided to residents. Pre-inspection comment cards received prior to the fieldwork visit were on the whole positive. Two cards received from healthcare professionals were complimentary, eight from residents gave positive comments but two indicated that they did not receive sufficient information prior to admission. The home discusses the standard of the services during residents and staff meetings. The registered manager was requested to re-commence distribution of resident’s questionnaires, to carry out audits and to produce a report including any shortfalls and timescales for their resolution. Such practices will ensure that the home is striving to make continual improvements for the good of residents. The arrangements for the safekeeping and financial transactions of residents personal monies are robust, this prevents financial abuse of residents. The accident records are good and there is evidence of investigations and action taken to reduce risks where a trend has been identified. All relevant checks and servicing of equipment are carried out to ensure that they are fit for purpose. The fire alarm and emergency lighting systems are regularly checked and the findings recorded to protect residents from harm in the event of an emergency situation. Further regular checks are carried out on the premises and emergency exit doors. Regular fire drills are carried out and the names of those staff who have participated are recorded to ensure that all staff are captured. The arrangements appear to protect residents and others from the risk of injury. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 23 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4(1)(a,b) Requirement The registered person must amend the statement of purpose to reflect the respite and interim care beds and be updated regarding the registered managers qualifications. The registered person must further develop the contract of terms and conditions of residency to include the room occupied and details of the services included and not included within the fee rate. Timescale for action 31/12/06 2. OP2 5(1)(b) 31/12/06 Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 25 3. OP7 15(1) 4. OP9 13(2) 5. OP18 13(6) 6. OP20 16(2)(c) 7. OP30 18(1)(c)(i ) 18(1)(c)(i ) The registered person must further develop care plans to include: • Details of residents personal preferences for daily routines and personal hygiene • Difficult to manage behaviour need to include the possible triggers and type of behaviour displayed • Record the residents life history and background • Develop care plans for short term illnesses such as urinary or chest infections. The registered person must ensure the practice of signing to confirm that medication has been consumed before offering the medication to residents. The registered person must ensure that all care staff receive training in Adult Abuse and that they possess the knowledge and skills to respond appropriately in allegations of suspected abuse. The registered person must undertake an audit of all armchairs and repair or replace any damaged or worn items. Timescale of 30/03/06 has not been met. The registered person must ensure that all care staff receive training in Health and Safety. The registered person must ensure that all care staff receive regular refresher courses in Moving and Handling. 20/12/06 31/10/06 31/01/07 31/01/07 28/02/07 8. OP30 28/02/07 Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 26 9. OP33 24 The registered person must include consultation with all stakeholders in the quality assurance process and draw up an annual development plan indicating outcomes for residents. Timescale of 30/06/06 has not been met. 31/01/07 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. 3. Refer to Standard OP1 OP16 OP19 Good Practice Recommendations The home is advised to produce the service user guide in large print and/or audiocassette for the benefit of those residents who have visual impairment. The home is advised to produce the written complaints procedure in large print and/or audiocassette for the benefit of those residents who have visual impairment. The home is advised to repair the facia of the hot trolley used in the main dining room. Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Bushmere EPH DS0000033446.V316027.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!