Inspection on 26/07/05 for Bushmere EPH

This inspection was carried out on 26th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bushmere EPH 03/01/08

Bushmere EPH 10/10/06

Bushmere EPH 13/12/05

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 Announced 26 July 2005 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 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 E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bushmere EPH Address 137 Edenbridge Road Hall Green Birmingham B29 2AU 0121 777 8308 0121 777 3714 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Birmingham City Council Care Home Category(ies) of 35 registration, with number of places Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 2. Registration category will be 35(OP). 3. Minimum staffing levels are maintained at 5 care assistants plus a senior member of staff throughout the waking day of 14.5 hours. 4. 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. 5. Care/shift manager hours and ancillary staff should be provided in addition to care staff. Date of last inspection 15 February 2005 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 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 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. There are bathing, showering and toilet facilities throughout the home. The home offers a service to 33 long stay residents and two respite care residents who require residential care with a variety of needs and dependancy. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was conducted over two days commencing at 8.00 am on 26th July 2005. This was the first statutory inspection for 2005/2006. The manager was present for the duration of the inspection. During the inspection process the inspector toured the home, sampled residents files and other documentation. The manager, three members of staff, approximately fourteen residents and two relatives who were visiting were spoken to. The inspector received twenty-two comment cards from residents, relatives and health professionals with their comments about the service. The feedback was overwhelmingly positive. One stated, “The staff are very pleasant, caring and professional. There is a happy atmosphere in the home which residents appreciate”. What the service does well: The home is friendly, relaxed and homely. 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. All residents stated they were happy in the home and felt they were very well looked after. Routines are flexible and they there is no restriction on visiting. Feedback from relatives indicated they were very happy with the home and they liked the relaxed atmosphere. Two responses indicated they would have no hesitation in recommending the home to others. Feedback was received from health professionals, which indicated the home provides a good standard of care and staff are caring and professional. The staff stated they were happy working in the home and felt they worked well as a team. They found the manager approachable and supportive. There were good systems in place for staff meetings and supervision. Also the home has regular consultation with residents to obtain feedback from them about the services provided. There is a varied menu with a choice of meals and ample portions, which was appreciated by residents. The home is cleaned to a high standard and generally well maintained providing a safe environment for residents. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 6 The standard of recording in care plans was generally good providing staff with sufficient information to ensure consistency of care. There has been a good range of staff training providing staff with the knowledge and skills to look after the residents. The home has recently had a quality assurance audit and scored highly. 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 E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 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 standard(s) 2,3,4,5,6 Information is available for prospective residents enabling them to make and informed decision about moving into the home. There were good procedures for admission to the home and written assessments were available with information about residents needs. EVIDENCE: The home generally admits residents for long term care, but have the facilities to admit two residents at any one time for respite care. They have information available for prospective residents, which the manager stated had been updated since the last inspection, but this was not viewed at the time of inspection. The home liaises with social workers that provide written assessments or care plans for residents who wish to enter the home. They 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. On inspection of records for a resident who had recently been admitted to the home there was evidence that this process had occurred. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 9 At the time of visiting the inspector spoke to some residents who had recently moved into the home and they expressed satisfaction with the home confirming that they had visited before moving in. Following admission to the home staff draw up an Individual Service Statement (ISS), which outlines resident’s needs and the action required by staff to meet their needs. A review is undertaken at the end of one month. There was evidence of contracts on some files inspected, but there was no evidence of the terms and conditions of residency. Staff have undertaken a range of training and are currently undertaking training in respect of dementia, dealing with challenging behaviour and stress. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. The medication system needs some improvements to ensure residents are safeguarded. 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 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 residents needs. A resident had recently been admitted to the home on respite care and there was no ISS available. The home had risk assessments, nutritional assessments and assessments of tissue viability and all had been reviewed monthly as required. On inspection of the nutritional assessments and tissue viability assessments they were found to be a little confusing and did not accurately reflect current situations. Also there was no clear indication regarding the significance of the scoring system. Residents are weighed intermittently. The inspector felt that these areas need to be addressed and staff would benefit from some training in this area. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 11 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. On discussion with residents they confirmed that they receive visits from the chiropodist, dentist and optician and this was confirmed on inspection. The home has some pressure relieving equipment in place for residents who are at risk of developing pressure sores. Written feedback from health professionals was positive stating the staff are pleasant, professional and compassionate. They found staff communicated clearly with them and demonstrated and clear understanding of residents needs. 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 on the medication it was noted that some audits were not correct; some medication had been signed as administered, but remained in the cassette. Also handwritten medication details had not been countersigned by two members of staff and two staff had not signed for the receipt of controlled medication. The home has a drug fridge and daily temperatures are recorded, however the minimum and maximum temperature should be recorded. On discussion with resident’s they stated they were happy living in the home, they found the staff very good and helpful. Residents stated they had 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. During inspection residents were well presented, their privacy was respected and staff treated them with dignity. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Catering and meals are well managed with a balanced and varied selection of food, which is tailored to residents individual choice. Residents are able to make choices about daily living activities and there is a relaxed, friendly atmosphere in the home with a range of leisure activities available. EVIDENCE: Residents are free to come and go as they wish and there are no rigid rules. Visiting is flexible and feedback from relatives indicated that they were made welcome by staff and were kept informed of any changes. The home has a range of entertainment and activities in house. An entertainer visits on bank holidays, there are exercises to music every two weeks and on Saturday nights they have a fun night with bingo and a sing a long. They also have some fund raising event such as table-top sales and are in the process of planning a car boot sale. The funds are used for residents and a trip has been organised to Weston Super Mare later this month. 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 on inspection and bedrooms had been personalised. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 13 The hairdresser visits the home each week and a religious service is held in the home each month. The library service visits monthly and pat a pet visit every fortnight. The home produce a newsletter every month, which is given to residents and posted to relatives keeping them updated with any changes in the home. In addition, there are regular meetings with residents to discuss various aspects of the home and if they have any comments or complaints. Each of the units has a television and radio and there is also a video library for film sessions. The home employs separate catering staff who provide three full meals per day. There is a four-week menu with choices available and it was stated that alternatives are available if residents did not like the menu of the day. On discussion with residents they all stated they enjoyed the meals, received a choice with ample portions. The inspector had lunch with the residents and found the meal to be hot and tasty and of a good standard. Meals were well presented and staff gave assistance where required. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home handles complaints appropriately and residents are assured that any concerns would be addressed. EVIDENCE: On discussion with the manager she stated that the complaints procedure had been updated to inform residents how to contact the Commission if they wished, but this was not inspected. The home had received one formal complaint since the last inspection, which had not been upheld and records were available for inspection. They had recently received one informal complaint, which the manager was dealing with it, but there was no record of the complaint at the time of inspection. It is recommended that all informal complaints be recorded also. One resident stated should would wonder what had gone wrong if she had reason to complain. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19,20,21,22,23,24,25,26 The home has a relaxed and friendly environment, which is maintained to a good standard providing and homely place for residents to live. Some redecoration is required. EVIDENCE: The building is a purpose built residential unit, which was odour free and cleaned to a high standard. There is a pleasant garden and patio area with seating to the rear of the building for use by residents when weather permits, which was secure. 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. The home has replaced some of the commodes and stated that more are to be replaced this year. 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. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 16 Each unit has a lounge, dining room and small kitchenette. Two of the dining rooms require decoration plus doorframes and skirting boards. Some of the borders were torn along the corridors, some bedrooms were in need of decoration and some of the kitchen units were starting to shown signs of wear. 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. 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. This area needs to be reviewed to ensure good infection control procedures. The main kitchen is situated on the ground floor and was found to be clean and orderly. However, the covering on the hot trolleys was damaged and action must be taken to address this as effective cleaning cannot be undertaken. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,2930 Staff morale was good, they were enthusiastic and there was noted to be good relationships between staff and residents. Satisfactory staffing levels are maintained and a range of training is undertaken providing staff with the skills to care for residents. EVIDENCE: The staffing rotas indicated there are five care staff on duty during the day plus senior staff. There is two care staff on duty overnight and one of the senior members of staff sleeps in on the premises. The care team are supported by administration staff, a maintenance operative, domestic and catering staff. It was stated that there were good relationships with the ancillary staff with meetings being held each month. There is a stable staff group with a low staff turnover. The home has an ongoing training programme and approximately 47 of care staff have completed NVQ level 2 and further staff are currently undertaking the training. All staff undertake in house induction training plus induction to TOPPS standards where appropriate. A small sample of staff files were inspected and were found to be of a good standard with evidence of robust recruitment procedures. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,22,35,36,38 The manager, who is supported by the senior team, provides good leadership. The home is managed in the interests of the residents and their health, safety and welfare is protected. 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 is waiting for an interview with the Commission for registration. On discussion with staff they stated they found the manager approachable, supportive, fair and she related well to residents. Staff stated that staff meetings were held regularly and they could raise any issues they wished for discussion. Records indicated that staff had regular formal supervision. Feed back from residents and relatives was very positive and all confirmed they were satisfied with the standard of care provided. The home holds Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 19 meetings with residents every month to obtain feedback and a news letter is distributed keeping them up to date with any changes. A sample of records was inspected in relation to maintenance and servicing and were found to be up to date. The water from hot water outlets in baths and showers are checked weekly to ensure it is safe, but it is not checked wash hand basins. There were records of weekly fire testing and a number of staff had undertaken regular fire drills. Records in relation to staff training indicated that a variety of basic training had been completed with the exception of infection control. It was recommended that the home develop of matrix to clearly demonstrate all training completed by staff. The home has recently completed a quality assurance audit and scored highly. The team manger visits every month and the manger stated she was very supportive. The home has a secure facility and holds money on behalf of some residents. On inspection of the records and money they were found to be of a good standard. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 3 3 x 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 3 15 3 COMPLAINTS AND PROTECTION 2 2 2 3 3 2 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 4 3 x 3 3 x 2 Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 38 Regulation 17(2) Schedule 1 Requirement The statement of purpose for the home needs to include all the information detailed in Schedule 1 of the Care Homes Regulations. This was not assessed at the time of insepection and has been carried forward from 10/1/04. The registered person must ensure all residents receive a statement outlining the terms and conditions on entering the home. The registered person must draw up a care plan for residents in the home for respite care. The registered person must ensure; Staff have a full understanding of assessments in repsect of nutriton and tissue viability. All reisdnets are weighed regularly. The registered person must ensure: The correct administration and recording of medication. Two staff countersign all handwritten medication details. Two staff sign for the receipt of all controlled medication. Timescale for action 30/11/05 2. 2 5(1)(b) 30/11/05 3. 4. 7 8 15 12(1) 15/8/05 30/8/05 5. 9 31(2) 30/7/05 Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 22 6. 9 13(2) 7. 20 23(2)(d) 8. 20 23(2)(b) 9. 19 13(3) 10. 21 23(2)(n) 11. 22 23(n) & 12(4)(a). 12. 24 23(2)(d) 13. 24 The minimum and maximum temperature of the drug fridge is recorded daily. Alternative storage arrangements must be explored for medication other than in unit kitchens. Timescale of 10/12/03 not met. The registered person must ensure the dining rooms on the first and second floors are redecorated. Timscale of 5/4/04 not met. The registered person should ensure the fooring in the first floor dining room is replaced as it is very discoloured. Timescale of 15/2/05 not met. The registered person must: Take action to address the damaged covering on the hot tolleys. Undertake an audit of units in kitchenettes and replace any damaged 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. The registered person should continue with the programme of 30/11/05 30/12/05 30/12/05 30/9/05 30/3/06 30/3/06 30/12/05 30/3/06 Page 23 Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 replacment of commodes. 14. 25 23(2)(p) The registered person must ensure Central heating controls are accessible to residents. Timscale of 10/4/04 not met. The registered person must ensure there are suitable handwashing facilities in all sluices. A minimum of 50 of care staff must be qualified to NVQ level 2 or equivalent. The manager of the home must be qualified to NVQ level 4 in care and management or equivalent. The registered person must ensure all staff undertake a fire drill and it is repeated at least twice a year. The registered person must ensure that all staff undertake training in repsect of infection control. The registered person must ensure the temperature of water from hot water outlets are checked in wash hand basins accessible to residents. 30/3/06 15. 26 13(3) 30/8/05 16. 17. 27 31 18(1) 9(2)(b)(i) 30/12/05 30/3/06 18. 38 23(4)(e) 30/8/05 19. 38 13(3) 30/12/05 20. 38 13(4) 30/8/05 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. Refer to Standard 16 Good Practice Recommendations It is recommended that all informal complaints are recorded. Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Birmingham and Solihull Local 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. Extracts may not be used or reproduced without the express permission of CSCI Bushmere EPH E54_S33446_BushmereEPH_V232626_260705 Stage 4.doc Version 1.30 Page 25 - 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!