Inspection on 03/01/08 for Bushmere EPH

This inspection was carried out on 3rd January 2008.

CSCI found this care home to be providing an Good service.

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 10/10/06

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 B28 8PN Lead Inspector Karen Thompson Key Unannounced Inspection 3rd January 2008 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bushmere EPH DS0000033446.V354587.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.V354587.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bushmere EPH Address 137 Edenbridge Road Hall Green Birmingham B28 8PN 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 Not known Birmingham City Council (S) Mrs Rita Bridget Gardner Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 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 14.5hours 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. 10th October 2006 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 accommodates a large dining room, lounge, a small smoking room, the main kitchen, laundry and medical room in addition to some bedrooms. The manager’s office is also situated on the ground floor enabling easy of access. On each of the other units, Hollyhocks Unit, 1st floor and Emmerdale Unit, on the 2nd floor there is a lounge, dining room and kitchenette. Residents who are reasonably mobile can 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. Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 5 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 located in reception provides a wealth of information and copies of inspection reports for residents and visitors to access. The prices for these services vary depending on the level of care required and financial assessment by the Department of Adults and Communities. Fees at the time of inspection ranged from £64.65 to £482.00 per week. Hairdressing, chiropody, dry cleaning, dental care, optician and toiletries are not included in the weekly fees. For up to date fee information the public are advised to contact the home. Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that needs further development. This inspection was unannounced and conducted over two days commencing on 3 January 2008. The manager was present for the duration of the inspection. Information was gathered from a number of sources: a questionnaire was completed prior to the inspection by the manager (AQAA) and on the day of the inspection a tour of the building was undertaken, records and documents were examined in relation to the management of the home, conversations took place with managerial and care staff plus visitors and residents. A number of residents were unable to communicate their views verbally to the inspector so direct and indirect observation was used to assist with the inspection process. Three residents who live in the home were ‘case tracked’ which involved establishing the individuals’ experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes of their lives in the home. Tracking people’s care helps us understand the experience of people who use the service. The quality of this service is 2 stars. This means the people who use this service experience good quality outcomes. What the service does well: This is a well managed home with a core staff group committed to delivering good care to residents. The home has lots of communal space, which provides residents with a choice of areas they can access for company or quiet space. There are good links with an array of multidisciplinary health professionals, which ensure that residents’ health needs are being met. Residents’ rooms are individualized with personal possessions so providing a more homely environment. Residents’ clothes were nicely laundered and they looked well presented. Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 7 Staff interaction with residents was relaxed and friendly ensuring a happy atmosphere within the home. Residents and relatives comments included “staff were kind” and “staff friendly and helpful”. Staff are recruited safely ensuring all required checks such as CRB disclosure are made before appointment; protecting residents when new staff are employed. Visiting was flexible and the staff welcome visitors, so residents are able to maintain contact with friends and family at a time that suits. The staff were able to demonstrate that pre-admission documentation was comprehensive, ensuring that residents are not admitted to the home unless their needs can be met appropriately. What has improved since the last inspection? What they could do better: The Management of homely remedies needs developing to ensure the administration and recording is accurate and residents’ safety is maintained. Staff training is needed in a number of areas e.g. manual handling, first aid, food hygiene, challenging behaviour and health and safety to ensure staff have the skills and knowledge to meet residents’ needs. Further work is required to ensure that social activities are tailored to individual needs and preferences. Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 8 Maintenance issues need to be addressed swiftly to ensure that residents’ health and well-being are not adversely affected. Staff must be provided with liquid soap, paper towels and bins in areas designated for hand washing to reduce the risk of cross contamination. The frequency of fire drills within the home must increase to ensure that all staff take part in a fire drill at least twice a year. 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.V354587.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.V354587.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, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the service or facilities was available to residents and/or their representatives to enable them to make an informed choice about the home. The pre-admission assessment process was consistently comprehensive and therefore residents can be assured their needs will be meet when moving into the home. EVIDENCE: The Statement of Purpose was not inspected during this visit. The Service Users’ Guides were observed in residents’ bedrooms. The Care Manager stated that the Service User Guide was available in other formats if residents required. The Service User guide needs to contain current information in relation to the range of fees charged by the home. Fees are calculated on an individual basis by the social work team based on residents’ needs and Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 11 finances. However the home will still need to state the highest and lowest fees charged to give potential residents an idea as to the possible range of fees. A number of residents’ files were inspected to determine the admission process. The pre-admission assessments information obtained by the home met the standard ensuring staff had sufficient information to meet residents needs when moving into the home. Bushmere EPH DS0000033446.V354587.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, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of the care plans for the majority of residents were good demonstrating needs were being assessed and that there were strategies in place to meet them. There was evidence of good multidisciplinary working taking place on a regular basis. The arrangements for medication administration were variable potentially placing residents at risk. EVIDENCE: The care records of three of the people living at the home were looked at in detail and other records were sampled. Care plans are based on the assessment that is completed before the person moves into the home. The care planning documentation is comprehensive with an array of risk assessments such as skin integrity, nutrition and moving and handling. The staff have worked as a team in reviewing the format used to record care planning needs and this is to be commended. The care plans are individualized Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 13 setting out the action to be taken by care staff to ensure aspects of health, personal and social care needs of residents are met. There were good examples of individual detail in these plans. Care plans, however were not always found to contain care-planning strategies for short-term medical conditions. Care plans did not acknowledgement how long term chronic conditions could be affecting on a residents care needs in some instances. These areas will need to be addressed to ensure consistency of care. The majority of daily recordings were detailed so ensuring that care delivery and the monitoring of needs could be ascertained and met. Information from these daily records were not always being linked back into the care planning strategies. The home accepts residents with dementia. Staff were able to demonstrate that residents needs in relation to cognitive impairment were being meet via a variety of means such as monitoring behaviour and referral to the appropriate professionals where required to ensure needs were met. Staff were also seen to deliver care based on acknowledging residents strengths to compensate for residents cognitive weakness. Some staff have received training in dementia awareness to provide them with the skills to meet residents needs. Staff however have not received training in challenging behaviour and this might account for poor documentation in this area. Whilst staff were making the appropriate referrals, records need to demonstrate whether staff can and have identified triggers for such behaviour. Residents’ files demonstrated that a variety of multi-disciplinary team members were visiting the home and referrals were being made. Staff were also able to demonstrate a pro-active approach to meeting residents health needs. The inspector observed a number of health professionals visiting the home during the fieldwork visit. Feedback from one health professional was positive in relation to how the staff work to ensure residents health needs are being met. The medication trolley is stored in a medication room. Medication trolleys were observed to be clean and organized. The home’s medication system consisted of a blister and box system. Staff photocopy the original prescribing script (FP10), which are used to check medication into the home. The majority of medication audits were correct with the exception of one boxed medication, which could not be audited, as medication had not been carried forward from the previous month. Homely remedies given out are not being recorded on the residents MAR chart. The home will need to ensure that this occurs as well as recording in the homely remedies book, which is used for a stock count of medication. Also there was no policy or procedure in respect of homely remedies The home will need to develop a policy and procedure for administration of homely remedies in consultation with their pharmacist to ensure the safety and well Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 14 being of residents. They will also need to get approval from the G.P’s caring for residents that they are happy for homely remedies to be given outside the normal prescribed medication Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 15 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, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were no rigid routines and visitors could visit at times that suited them enabling residents to maintain contact with them. The home needs to review activity provision for residents to ensure they led a stimulating and purposeful life EVIDENCE: Activities were taking place inside and outside the home. Some residents had been out for a Christmas meal and a X-mas party had occurred in the home for residents with an external entertainer. There had also been a New Year party for residents with another visiting external entertainer. Residents spoken to during the inspection confirmed that they had enjoyed the Christmas and New Year activities. On the first day of the visit the inspector was able to see how the home had been decorated for the festive session. The decorations gave a welcoming and happy atmosphere to the home. Internal activities within the home included as exercise sessions and bingo. The Care Manager informed the inspector that manicures were taking place but these had not been recorded in the records. The care plans contained no social history or background profiles of residents’ life and interests to enable individualised plan Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 16 to meet residents’ needs. Further work is needed to tailor activities to the specific needs of residents, as records do not confirm this is taking place. Residents confirmed there were no restrictions on their activities and that they could go to bed when they wanted and get up when they liked. Visitors are welcomed to the home and offered drinks with the residents. Residents confirmed that they were able to leave the home and return with no restrictions. Staff chatted to during the inspection were able to demonstrate an individual approach to residents care. Residents’ bedrooms were personalized with their own possessions so providing a more homely environment. Staff were observed to assist residents discreetly and sensitively. Tables were laid nicely with linen tablecloths and condiments. Menus had been revised since the last inspection and were based on a nutritional advice. Residents’ comments about food were positive. Residents stated “get well fed” and “wouldn’t get any better food anywhere”. Residents’ individual preferences in relation to food are catered for. Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 17 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that residents are protected and their concerns listened to and processed in a sensitive and professional manner. EVIDENCE: The home has a comprehensive complaints procedure. The home has received two formal complaints since the last inspection. One adult protection was referred to Adults and Communities. The home was able to demonstrate that they had investigated the concerns appropriately, professionally and an action plan was drawn up to ensure any findings were addressed. Residents and relatives spoken to during the inspection stated that they would go to the management team with concerns and that the management team was approachable. Arrangements for protecting residents within the home were in place. The Care Manager informed the inspector they had a copy of the multi-agency guidance policy and procedure. The majority of staff have received training in adult protection. Staff interviewed during the fieldwork visit were able to demonstrate a good knowledge in relation to abuse and safeguarding procedures. Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 18 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, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Progress has been made in addressing outstanding maintenance issues and as a result the building externally and internally has improved making it homely, safe and pleasant in a number of areas. Residents’ private accommodation is suited to their needs and personalised according to their tastes and preferences. EVIDENCE: The home has made progress in a number of areas in addressing outstanding maintenance, redecoration and refurbishment issues. New armchairs and new carpet has been fitted in areas through out the home. The kitchenette on the top floor of the home has been refurnished. The building is purpose built for residential care and is cleaned to a high standard. Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 19 Each floor has its own unit, which consists of a lounge and a dining room with kitchen off. Residents are encouraged to access all floors to socialise with other residents. There is also a light, airy reception area where people can sit and access the large supply of written information. The hairdressing salon is situated on the second floor and has good facilities for residents’ comfort. There is also an enclosed garden with seating for residents and visitors to frequent when weather permits. There is a shower and bath on each floor along with toilet facilities. The assisted bath was found not to be working on the top floor. The Care Manager informed the inspector that they had received quotes for repair of the baths. It is imperative that these repairs take place as quickly as possible to promote and protect the dignity of residents. 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. Good procedures were in place 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 risk associated with COSHH items. Staff wore protective equipment to ensure lack of cross infection. Hand washing facilities have been made available in sluice rooms around the home, however staff do not use this facility but leave the sluice to wash their hands in the bathroom sinks. There was not liquid soap, paper towels or waste bins in this area to enable staff to wash their hands. Thus the fitting of the sinks in highrisk areas had not altered staff practice, as they are unable to use them therefore placing themselves and residents at potential risk of infection. Since the previous inspection, the kitchenette area on the top floor has been refurbished however on the day of the inspection the dishwasher was observed not to be working. Staff were washing crockery up by hand meaning that the crockery is not being washed at the recommended temperature in a communal setting to reduce risk of contamination and infection. Armchairs have been replaced improving the environment for residents to live in. The facia of the hot trolley has been repaired since the previous inspection, so enhancing facilities. Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 20 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, 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 adequate to meet the needs of residents. The recruitment and selection procedures ensure that residents are protected. The home has a committed workforce but training has elapsed in some areas and this needs to be resolved so that residents receive a service from a competent and skilled team. EVIDENCE: There were twenty-nine residents living in the home at the time of the inspection. Rotas demonstrated four to five carers along with senior staff support is available during the day. There are two night staff on duty with a senior member of the team sleeping in the home, but available in case of emergency. Two recently recruited staff files were inspected and it was found that a satisfactory recruitment process had been implemented with an application form, health declaration, two references and Criminal Record Bureau Check ensuring residents are protected by the employment of new staff. Twelve of the six staff have completed NVQ 2 or above bringing the percentage of staff with this qualification to approximately 66 . Thus ensuring that staff Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 21 have the skills and competences to meet the needs of residents. Staff files were sampled for certificates to demonstrate training had taken place and these were found to be available. The home has a training matrix, which gives an overview of training that has occurred for all staff working at the home. The training matrix identified shortfalls in manual handling, first aid, food hygiene and health and safety training. The inspector was informed that various staff have been nominated recently to attend these courses. The induction programme meets the Skills Council standard and is carried out at the home and also at the providers training venue Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 22 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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well-managed home run for the benefit of residents. The health, safety and welfare of residents and staff are generally promoted and protected EVIDENCE: The home has a Care Manager with a wide breath of experience and knowledge. The Care Manager is assisted by a management team and group of staff that work well together as a team. There was a friendly happy relaxed atmosphere in the home. The home’s documentation was well organized and easy to access. There is a written record of residents’ money with receipts. Money is held individually and securely. The arrangements for the safekeeping and financial Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 23 transactions of residents’ personal monies are robust, so protecting residents’ finances. The home has various systems in place to monitor quality assurance, which include environmental checks, and audits carried out against CSCI standards, resident, staff and quality assurance meetings. The home had conducted resident and staff surveys, which were being analysed. From the information gathered the home should be able to demonstrate that the service is being tailored to residents aspirations and needs. Health and safety matters on the whole were well managed. A fire risk assessment was in place. Fire drills for staff had occurred two times in the past twelve months. Checks were being carried out by the maintenance operative in areas such as hot water, fire equipment and procedures. There was evidence that hoists were being served and maintained. The home was unable to locate the most recent lift-servicing certificate at the time of the visit. Gas appliances were being serviced and had the appropriate safety certificates. The home has recently received a letter from Birmingham City Council head of food, stating the home was judged very good in relation to a hygiene inspection undertaken by an environmental health officer. Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 24 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 X 3 X X X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 2 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 3 X 3 X X 2 Bushmere EPH DS0000033446.V354587.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(1) 12(1) Requirement The registered person must further develop care plans to include: Develop care plans for short term illnesses such as urinary or chest infections. Requirement not meet at 20/12/06 Care plans should also contain information for staff on how to meet the needs of residents with long-term chronic medical conditions. Residents identified with having challenging needs should have these needs recorded and monitored in the care planning process A homely remedies policy and procedure should be devised with the consultation of the homes pharmacist and G.Ps. All staff administering homely remedies must be familiar with the policy and procedure to ensure the well being and safety DS0000033446.V354587.R01.S.doc Timescale for action 03/04/08 2 OP9 13(2) 03/03/08 Bushmere EPH Version 5.2 Page 26 of residents in receipt of this medication. 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 4 5 6 7 8 Refer to Standard OP1 OP12 OP26 OP30 OP33 OP38 OP38 OP38 Good Practice Recommendations The Service Users Guide must contain range of fees charged for accommodation to ensure residents are fully informed. Residents social preference must be assessed and activities tailored to these. Liquid soap, paper towels and bins must be available by staff hand washing sinks to reduce the risk of cross contamination. All staff must receive up to date training in fire awareness, food hygiene, challenging behaviour manual handling, health and safety and first aid. Following analysis of the quality assurance data the home must draw up an action plan to meet any identified needs or shortfalls The assisted bath must be repaired and available for use by residents, so as not to impact on the privacy and dignity of residents. The dishwasher must be repair on the top floor of the home, to reduce the potential risk of contamination. All staff must part take in a fire drill twice a year to ensure they have the knowledge and skills in the event of a fire to maintain residents and their own safety. Bushmere EPH DS0000033446.V354587.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.V354587.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. 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