Inspection on 13/12/05 for Bushmere EPH

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10/10/06

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 Ann Farrell Unannounced Inspection 13th December 2005 08:15 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.V273298.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 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) 777 8308 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.V273298.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 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 14.5hours 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 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 That Mrs Gardener successfully completes NVQ Level 4 in Management & Care by June 2006. 26th July 2005 Date of last inspection Brief Description of the Service: Bushmere House is a large, purpose built, 35 bedded home for older people, which is owned and managed by the Local Authority. The home offers accommodation to 31 long stay residents, 2 respite car and 2 interim care residents who require residential care with a variety of needs and dependency. Bushmere House 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 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. Bathing, showering and toilet facilities are strategically situated throughout the home. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted over one day commencing at 8.15 am on 13th December 2005. This was the second statutory inspection for 2005/2006 and this report should be read in conjunction with the report for the inspection of July 2005. The registered manager was present for the duration of the inspection. During the inspection process the inspector undertook a partial tour of the home, sampled residents files and other documentation. The home was clean, warm and well maintained providing a homely, welcoming environment. The managers and five residents were spoken to at the time of visiting. What the service does well: The home has a friendly, relaxed and welcoming atmosphere. The manager’s office is situated in the main reception area, enabling visitor’s easy access to discuss any issues or concerns. Staff are friendly and welcoming and there was noted to be a good rapport and relationships between staff and residents. There is a stable staff group and they continue to provide good standards of care and meet resident’s needs. All residents stated they were happy in the home and felt they were very well looked after. Routines are flexible and there is no restriction on visiting. Comments received included – “Staff are very kind” – “They can’t do enough for you, I can’t fault them”. There were good systems in place for staff meetings and supervision. Also there is regular consultation with residents to obtain feedback from them about the services provided. Staff also undertake three monthly audits as part of the quality assurance system. There is a varied menu with a choice of meals and ample portions and all residents spoken to stated the meals were of a good standard. The home is cleaned to a high standard and generally well maintained providing a safe environment for residents. The standard of recording in care plans was generally good. There has been a good range of staff training providing staff with the knowledge and skills to look after the residents. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 6 What has 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. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4,6 Information is available for prospective residents about the services and facilities. There were good procedures for admission to the home. EVIDENCE: The home generally admits residents for long term care, but have the facilities to admit two residents for respite care and now admit two residents for interim care. Interim care is usually for short periods for people leaving hospital before they return to their own home. They have information available for prospective residents and a copy was available in the reception area. The home liaises with social workers who provide written assessments or care plans for residents entering the home. Staff also invite prospective residents to the home enabling them to view the facilities, meet staff and other residents and partake in a meal. At this stage staff are able to undertake an initial assessment to determine if they are able to meet residents needs. At the time of visiting the inspector spoke to a resident who was on respite stay and he stated that he had settled into the home and found the staff helpful. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Good arrangements are in place to meet resident’s health care needs and care plans were comprehensive ensuring continuity of care. There have been some improvements in the medication system since the last inspection. EVIDENCE: The home draws up an Individual Service Statement (ISS) for each resident following admission to the home outlining how resident’s needs are to be met by staff. On inspection they were found to be of a generally good standard; they had been personalised to individual residents and provided detailed information about a range of areas and the action required by staff to meet the resident’s needs. However, some areas lacked detail, they had not been consistently dated when any changes had been made and there was no plan of care for the resident who was on respite care. At the last inspection it was found that staff undertook assessments of nutrition and tissue viability, which were a little confusing and it was recommended that staff training should be undertaken. This has not been undertaken to date. Staff were observed to be transferring residents in wheelchairs without footplates. This is a risk and should not be occurring unless a risk assessment has demonstrated alternatively. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 10 All residents are registered with a local G.P. Staff liaise with health professionals from the multidisciplinary team such as district nurses, social workers and continence adviser. The home has some pressure relieving equipment in place for residents who are at risk of developing pressure sores, but this was not consistently recorded in ISS’s. The home uses a monitored dosage system and medication is stored in the medical room or on individual units. It is recommended that more appropriate storage be found on the individual units. All staff who administer medication have completed accredited training. On inspection of the medication there was noted to be an improvement and the medication in the monitored dosage system was correct. Some of the audits of boxed medication were not accurate, handwritten medication details had not been countersigned by two staff and the timing for the administration of antibiotics had not been spread evenly over 24 hours. The medication room had a trolley that was not secured to the wall and new medication was not stored in a locked cupboard. On discussion with resident’s they stated they were happy living in the home, they found the staff were very kind and they could not do enough for them. Residents have keys to their doors and there were lockable facilities available in rooms. A public telephone is available in a separate room enabling telephone calls to be made in private, but it was locked. During inspection staff were noted to respect residents privacy and treat them with respect. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 There is a relaxed, friendly atmosphere. Although there is a range of activities, this area needs to be reviewed as some residents stated they would appreciate more. Catering and meals are well managed with a balanced and varied selection of food, which is of a good standard. EVIDENCE: Residents are free to come and go as they wish, there are no rigid rules and visiting is flexible. Each of the units has a television and residents were observed reading or talking to each other. Residents make take items of furnishings into their rooms and it was found that bedrooms had been personalised. The staff produce a newsletter regularly and copies were seen in residents rooms. On discussion with residents there was varied feedback in respect of activities, with some stating they were satisfied and others would appreciate more. The hairdresser visits the home each week and a religious service is held in the home each month. The home employs separate catering staff who provide three full meals per day. There is a four-week menu with choices available and alternatives are available if required. On discussion with residents they all stated they enjoyed the meals, received a choice with ample portions. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents and their relatives can be assured that they are protected. EVIDENCE: Vulnerable adult procedures are available in the home and staff are undertaking training in this area. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 The home is maintained and cleaned to a good standard providing and homely environment for residents to live. Some re-decoration and aspects of infection control need to be addressed. EVIDENCE: The building is a purpose built residential unit, which was odour free and cleaned to a high standard. There is secure, pleasant garden and patio area with seating to the rear of the building for use by residents when weather permits. The home is divided into three separate units, one on each floor. All bedrooms are single and have a wash hand basin and call bell. All rooms have locks to doors and residents may have a key. In addition, there are lockable facilities available in rooms if they wish to keep any valuables or medication. A further ten commodes have been replaced since the last inspection and quotes have been obtained for re-decoration and replacement of some floors. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 14 Each unit has a lounge, dining room and small kitchenette. Some of the kitchen units were starting to show signs of wear and some of the armchairs require repair or replacement as the arms and cushions were worn. There is a range of bathing facilities on each unit, which would benefit from being made more domestic in character. However, two of the bathing facilities remain unsuitable for the needs of the residents and are not used. Consequently there is only one appropriate facility on each floor, which is not adequate for thirty-five residents. There were numerous toilets throughout the home within easy access of dining rooms and lounges. There were two blocks of three toilets on the ground floor consisting of one larger toilet and two smaller ones. However, the design of these makes it very hazardous for staff and residents to use with the door closed and there was little room to manoeuvre a wheelchair. The other two toilets in each block were very difficult for residents with walking frames to access. Rooms are individually and naturally ventilated and windows are provided with restrainers. It was noted that some of the over sink lights were not working in bedrooms. An audit of all rooms should be undertaken. All areas are centrally heated, but controls to the radiators cannot be accessed by residents to adjust the heating in individual bedrooms. Hot water outlets have thermostatic valves fitted to control the temperature of hot water to reduce risks from scalding. There is a separate laundry, which is adequately equipped and undertakes the laundering of residents clothing. There are separate sluice facilities, one having a sluicing disinfector. Practice involves washing out commode pots by hand in the sink in the other sluices. It was noted there was not a separate hand basin for staff hand washing. Since the last inspection staff have been provided with individual gels for hand cleaning. At the time of inspection it was noted that some staff were walking around the home with gloves on and some soiled clothing had been discarded on the floor. These areas need to be addressed to improve practices in respect of infection control. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Satisfactory staffing levels are maintained and a range of training is undertaken providing staff with the skills to care for residents. EVIDENCE: Staffing levels appeared satisfactory at the time of inspection. There is a stable staff group with a low staff turnover. On discussion with residents they stated, “staff are very helpful and I cannot fault them”. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,38 The manager, who is supported by the senior team, provides good leadership. The home is managed in the interests of the residents and they are regularly consulted about aspects of the home. Their health, safety and welfare could be further protected through addressing the issues identified by the fire officer. EVIDENCE: The manager has been in post for approximately eighteen months and has had several years experience working with the elderly. She has almost completed the Registered Managers Award and has been successful in registering with the Commission. The manager stated all assistant managers have been nominated to undertake the Registered Managers Award. Also night staff and herself have been nominated for first aid training The senior staff undertake quality monitoring through monthly meetings with residents and three monthly audits of various aspects of the home. However, there is no consultation with other stakeholders and no annual development Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 17 plan, which is required in order to meet the standards. It was stated that the team manager visits regularly, but there was no evidence of the monthly reports available as required in order to meet the regulations. A sample of records was inspected in relation to maintenance and there was no evidence of monthly checks for the emergency lighting or hot water outlets in resident’s rooms. The fire officers were visiting at the same time and they identified some areas that require attention. Records of training and fire drills for staff were a little confusing, but it appears that all staff had not undertaken two fire drills in the last year. Records in relation to staff training indicated that a variety of basic training had been completed with the exception of infection control, which is due to commence next week. It was recommended that the home develop of matrix to clearly demonstrate all training completed by staff. During inspection it was noted that a number of fire doors were propped open. This poses a risk and if there is a need to keep them open they should be linked into the fire alarm system. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 X 18 3 2 2 2 x 3 2 3 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 19 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 OP2 Regulation 5(1)(b) Requirement The registered person must ensure all residents receive a statement outlining the terms and conditions on entering the home. This area was not assessed at the time of inspection and has been carried forward from 30/11/05 The registered person must: • Draw up a care plan for residents in the home for respite care. • Ensure all care plans are updated, signed and outline in detail all aspects of care. The registered person must ensure staff have a full understanding of assessments in respect of nutrition and tissue viability. Timescale of 30/8/05 not met. The registered person must ensure that all wheelchairs used for transferring residents have footplates in place unless a risk assessment demonstrates alternatively. DS0000033446.V273298.R01.S.doc Timescale for action 30/05/06 2. OP7 15 30/01/06 3. OP8 12(1) 30/03/06 4 OP8 13(4) 30/12/05 Bushmere EPH Version 5.0 Page 20 5. OP9 13(2) 6. OP9 13(2) 7 OP10 12(4) 8. OP20 23(2)(d) 9. OP20 23(2)(b) 10. OP19 13(3) The registered person must ensure: • Two staff countersign all handwritten medication details. Timescale of 30/7/05 not met. • The correct administration and recording of all medication. • The medication trolley is secured to the wall and all medication is stored in a locked cupboard. • The administration of antibiotics is spread out evenly over 24-hour period. Alternative storage arrangements must be explored for medication other than in unit kitchens. Timescale of 10/12/03 not met. The registered person must review the arrangements for the telephone room to enable free access to all residents when required. The registered person must ensure the dining rooms on the first and second floors are redecorated. Timescale of 5/4/04 not met. Quotes have been obtained. The registered person should ensure the flooring in the first floor dining room is replaced, as it is very discoloured. Timescale of 15/2/05 not met. Quotes have been obtained. The registered person must: Take action to address the damaged covering on the hot trolleys. This area was not assessed. Undertake an audit of units in kitchenettes and replace any damaged items. Timescale of 30/9/05 not met. DS0000033446.V273298.R01.S.doc 30/12/05 30/03/06 30/12/05 30/06/06 30/06/06 30/03/06 Bushmere EPH Version 5.0 Page 21 11 OP20 16(2)(c) 12. OP21 23(2)(n) 13. OP22 23(n) 12(4)(a). 14. OP24 23(2)(d) 15. OP25 23(2)(p) The registered person must undertake an audit of all armchairs and repair or replace any damaged or worn items. There are two baths in the home, one on the ground floor, one on the second, which are inappropriate for the residents. Both of these should be replaced to ensure that appropriate bathing/shower facilities are available to residents. Timescale of 10/4/04 not met. The two blocks of three toilets on the ground floor need to be redesigned as accessibility for those in wheelchairs and with Zimmer frames is hazardous and in some instances privacy would be very difficult. Timescale of 10/4/04 not met. The registered person must ensure all parts of the home are kept reasonably decorated. Timescale of 10/1/04 not met. Quotes have been obtained. The registered person must ensure central heating controls are accessible to residents. Timescale of 10/4/04 not met. 30/03/06 30/03/06 30/03/06 30/06/06 30/03/06 16. OP26 13(3) 17. OP28 18(1) 18. OP31 9(2)(b)(i) The registered person must undertake an audit of all over sink lights and ensure they are in working order. The registered person must 30/12/05 ensure all staff remove their gloves and wash their hands after dealing with body fluids and soiled clothing is not left on bedroom floors. A minimum of 50 of care staff 30/05/06 must be qualified to NVQ level 2 or equivalent. This area was not assessed and has been carried forward from 30/12/05. The manager of the home must 30/03/06 be qualified to NVQ level 4 in DS0000033446.V273298.R01.S.doc Version 5.0 Page 22 Bushmere EPH 19 OP33 24 20 OP33 26 21. OP38 23(4)(e) 22 OP38 23(4) 23. OP38 13(4) care and management or equivalent. 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. The responsible individual must ensure someone undertakes a monthly visit on their behalf, write a report on the conduct of the home and a copy must be available in the home. The registered person must ensure all staff undertake a fire drill and it is repeated at least twice a year. Timescale of 30/8/05 not met. The registered person must ensure; • The issues highlighted by the fire officer’s report are addressed. • All fire doors are kept closed. If there is a need to keep them open they must be linked into the fire alarm system. • A record is retained in the home to demonstrate testing of the emergency lighting system The registered person must ensure the temperature of water from hot water outlets are checked in wash hand basins accessible to residents. Time scale of 30/8/05 not met. 30/06/06 30/01/06 30/01/06 30/03/06 30/01/06 Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 23 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 OP38 Good Practice Recommendations It is recommended that a review of social activities be undertaken. It is recommended that the manager draw up a training matrix to demonstrate the staff training that has been completed. Bushmere EPH DS0000033446.V273298.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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