Inspection on 14/03/06 for The Bush

This inspection was carried out on 14th March 2006.

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

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

Other inspections for this house

The Bush 04/03/09

The Bush 22/01/08

The Bush 24/07/07

The Bush 19/01/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Bush 37 Bush Street Wednesbury West Midlands WS10 8LE Lead Inspector Keith Salmon Unannounced Inspection 14th March 2006 09:30 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 The Bush DS0000064824.V286117.R01.S.doc Version 5.1 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. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Bush Address 37 Bush Street Wednesbury West Midlands WS10 8LE 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 526 5914 0121 526 5914 Rajan Odedra Usha Odedra Yvonne Margaret Lavender Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30 August 2005 Brief Description of the Service: The Bush is registered to provide personal care for 44 people over the age of 65 years and is jointly owned by Mr Rajan Odedra and Mrs. Usha Odedra, trading as ‘Bush Residential’. The Registered Manager is Mrs Yvonne Lavender. The property is a large, extended, detached building, once used as a Public House, from which the Home takes its name. Situated within walking distance of Darlaston Town Centre it is within easy reach of public transport and local amedities. The accommodation comprises 30 single and 7 double occupancy bedrooms over two storeys, with a shaft lift to facilitate access between floors, communal lounge/dining areas and conservatories. There are no en-suite facilities. The Home enjoys gardens which are easily accessible for Residents of all abilities, and a car park to the front of the building. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection commenced at 09.30, lasted 4.5 hours, and was undertaken by one Inspector. The aim of this Inspection was to assess progress made by the Home in meeting ‘Requirements’ cited at the previous Inspection and all ‘key’ Standards not addressed at that time. This Report is a product of discussions with the Deputy Manager (Yvonne Ireland), five Residents, two visiting Relatives and several members of Care Staff together with observations made during a tour of the Home. In addition, a review of documentation/records was undertaken, including Resident’s Care Plans, Staff recruitment/deployment records, and a range of documents/records reflecting the general operation of the Home. High standards of direct care are provided in an open and supportive atmosphere. What the service does well: 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. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 6 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 The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 7 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): 1,2,3,4. Prospective Residents, or in most instances their Relative/advocate), are generally enabled to reach an informed choice. However, Residents/Relatives may not, in all instances, have been made formally aware, prior to taking up residency, that the Home can meet their care needs. Prior to admission processes to ensure appropriate, thorough and effective care needs assessment are diligently undertaken and applied. Care Staff are enabled to provide the type and quality of care required by Service Users. EVIDENCE: Documentation reviewed demonstrated the Home has a Statement of Purpose and User Guide, which are concise, easy to read and contain relevant details which meet the requirements of the Standard. Evidence from 5 randomly selected Personal Files/Care Plans confirmed Service Users are provided with a Statement of Terms and Conditions detailing the accommodation to be provided, and the Registered Manager, or Deputy Manager, assess all prospective Residents/Service Users prior to admission. However, the Home does not currently issue a letter to prospective Residents, or their Relative/advocate, confirming the Home is able to meet the Resident’s assessed care needs. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 8 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 The model of Care Plan utilised by the Home is of good design and is generally effectively utilised in aiding the provision of care, pertinent to Residents’ assessed care needs. Care provided by the Home successfully meets the Residents’ assessed care needs. Staff relate to Residents in a friendly and respectful manner. Practices relating to storage, administration and disposal of medicines are generally in accordance with accepted good practice. EVIDENCE: Review of 5 randomly selected Care Plans demonstrated full pre-admission assessment having been carried out by suitably qualified staff. Care Plans are well-organised, clearly written and up-to-date. Individual discussions with Residents and Relatives confirmed Residents’ needs are being met. One area of criticism is the absence of identification photographs in some Care Plans, and in medicine administration records (MAR sheets). The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 9 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): 12,13,14. The Home works effectively at involving Residents in a comprehensive range of leisure opportunities consistent with each Resident’s capabilities. Residents are actively assisted in maintaining contact with relatives, friends and the local community and in the continuation of religious practices. EVIDENCE: Residents informed the Inspector they were able to pursue their own interests and join with other Residents in a range of leisure activities, which are planned and organised by an Activities Organiser who works in the Home during the afternoons. Activities include taking part in a weekly ‘Progressive Mobility‘ group, a trip to the West Midlands Safari Park, regular attendance at the Home of visiting singers/ entertainers, art and crafts sessions, quizzes, reminiscence sessions and traditional activities such as board games, dominoes and bagatelle. Evidence was observed of these activities in the form of a display of photographs covering many outings and sessions. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 10 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): Standards in this section not fully assessed at this Inspection. EVIDENCE: The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 11 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): 19,22,24,26. Residents do not live in a safe, well-maintained environment. Whilst the Home appears to provide an environment which is generally safe for Residents, Visitors and Staff it does not provide an environment which is well maintained. Specialist equipment necessary to facilitate provision of care, and is now safely stored. Residents’ bedrooms now have the facility for the fitting of door locks when required and in shared rooms the fitting of appropriate privacy curtains. The Home is clean, but the laundry area needs to be improved in relation to the level of décor (walls) and the provision/maintenance of suitable equipment capable of ensuring effective infection control. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 12 EVIDENCE: At the previous Inspection it was ‘Recommended’ a programme for routine maintenance and refurbishment/redecoration should be established. The Deputy Manager informed the Inspector the new Owners were very concerned regarding the lack of maintenance and redecoration/refurbishment previously carried out and were set to remedy this situation. This was confirmed directly to the Inspector by one of the Owners, Mrs. Odedra, who visited the Home during the Inspection. However, as such a programme has yet to be devised, and implemented, this ‘Recommendation’ will now become a ‘Requirement’. At the two previous Inspections it was noted the small lounge and conservatory were being used to store large pieces of equipment creating concern that the fire exit in the lounge could become obstructed. It was observed at this Inspection the Requirement to rectify this situation has been met. Since the previous Inspection some attempt has been made to improve the state of the laundry walls. However, the overall appearance remains shabby with some areas of paint and plaster peeling/crumbling away. It is understood the Responsible Persons are proposing to relocate the laundry to the cellar as part of a revision of the total accommodation. The Inspector understands discussions are being held with the CSCI in the near future in order to clarify this matter. The top-loader washing machine, identified as a concern in a ‘Requirement’ issued at the previous Inspection, continues to remain a considerable concern, from both a safety and infection control viewpoint. The problem is primarily due to there being no way of knowing whether the machine is capable of operating at the required temperature. Therefore, a washing machine must be installed, as soon as is practically possible, which can wash at an appropriate water temperature, i.e. 65o Celsius for not less than 10 minutes, and includes a display to confirm this temperature. This is to replace the top-loader washing machine presently in use. In addition, until the new machine is fitted, and if the top-loader remains in use, it must be subject to a structured and recorded cleaning programme, which includes removing excess powder/fibre residue from inside the rim of the load opening. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 13 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. The Home now has sufficient Ancillary Staff to undertake catering duties thus avoiding depletion of Care Staff numbers during the afternoon period. EVIDENCE: Discussion with the Deputy Manager, inspection of staff employment records, and discussions with Staff, showed changes have been made to staffing levels and skill-mix, to ensure care staff levels are not compromised due to Staff taking on roles additional to the provision of direct care. A staff training analysis and plan should be drawn up, together with the use of a monitoring tool, to ensure all Staff are receiving appropriate training and the annual amount meets or exceeds three days per person. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 14 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): 33,36,38. The Home is well organised with the clear central purpose being ‘the best interests of Residents’. Lines of accountability are clearly defined and observed and Staff are subject to effective support with regular supervision. Health and Safety Policies/Procedures/Practices were satisfactory EVIDENCE: Residents and Staff were seen to approach the Manager with a range of issues, which were received in an interested and involved manner. A matrix setting out individual staff training records was reviewed by the Inspector, which clearly showed Staff receive satisfactory induction, foundation and on-going training consistent with their own training needs. Records are maintained for the testing of the temperature of hot water supply to baths and hand-wash basins. Water tested during the Inspection was satisfactory. COSHH requirements were satisfactory and relevant data sheets up to date. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 15 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 3 3 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X 3 X 3 X 1 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 X X 3 X X 3 X 3 The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 16 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. Standard Regulation Requirement The Responsible Person(s) must ensure all prospective Residents or their Relative/advocate have confirmation in writing that the Home is able to meet the Resident’s assessed care needs. The Registered Manager must ensure there are identification photographs in the Care Plans of all Residents. The Registered Manager must ensure there are identification photographs in, or attached to, the medicines administration record (MAR sheet) for all Residents. Timescale for action 30/04/06 1. OP4 14.-(d) 2. OP7 17.-(1)(a) 30/04/06 3. OP9 13.-(2) 30/04/06 4. OP19 23.(2)(b)(d) The Responsible person must provide the CSCI with a refurbishment/redecoration plan, together with a programme for 31/03/06 the commencement and completion of all necessary works. The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 17 5. OP26 16.-(2)(j) 6. OP26 16.-(2)(j) 7. OP26 16(2)(j) 23(2b)(d) The Home must replace the present top loader washing machine with a model, which can wash at an appropriate water temperature, i.e. 65o Celsius for not less than 10 minutes, and includes a display to confirm this temperature. Whilst the top-loader washing machine remains in use is must be subject to a structured & recorded cleaning programme that includes removing excess powder/fibre residue from inside the rim of the load opening. The laundry walls must be ‘finished’ so they are readily cleanable and cleaning can be undertaken around and behind the machines. (Previous Requirement from 30 August 2005) N.B. It is understood the Responsible Persons are proposing to relocate the laundry to the cellar and is to be discussed with CSCI. 30/04/06 14/03/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 The Bush DS0000064824.V286117.R01.S.doc Version 5.1 Page 19 - 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!