Inspection on 19/01/07 for The Bush

This inspection was carried out on 19th January 2007.

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

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

Other inspections for this house

The Bush 04/03/09

The Bush 22/01/08

The Bush 24/07/07

The Bush 14/03/06

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 Chris Fuller Unannounced Inspection 19th January 2007 09:00 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 The Bush DS0000064824.V348250.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. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 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 *** Post Vacant *** Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may provide four places in the category of DE(E) for the existing four residents named in the application dated 12 July 2006 for the period of their residence in the home. Once the placement has ended the numbers revert to the original registration category of OP. 14th March 2006 Date of last inspection 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.V348250.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This year the Commission for Social Care Inspection is making a key inspection of a selected number of the National Minimum Standards. The focus remains on assessing the quality of care provided through the experience and outcomes for service users, a review progress on meeting statutory requirements from last years inspections and focusing on aspects of service provision that require further development, or pose the most significant risk to service users. The unannounced key inspection took place on Friday 19th January 2007. The deputy manager assisted throughout the inspection. The registered provider was available to contribute regarding future plans for development of services in the home and to receive feedback. The inspector made a tour of the premises including some individual rooms, the laundry, kitchen, hairdressing salon, cellar and bathrooms. The records and systems were seen including the administration of medication during the lunchtime period. The inspector spoke with several residents and members of staff and would like to thank them for their co–operation and help with the inspection visit. What the service does well: What has improved since the last inspection? Feed back from relatives stated “We have no complaints and we feel you are doing a very good job” The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 6 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 summary of this inspection report can be made available in other formats on request. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Bush DS0000064824.V348250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Quality in this outcome area is adequate. The Bush management will complete an assessment of needs with the prospective residents prior to admission and will inform them whether a placement can be offered. This needs to be formalised with a written letter confirming how their needs will be met to ensure they can make an informed choice regarding the suitability of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were twenty nine residents living at The Bush at the time of the inspection. Residents are admitted following an assessment of their needs by the senior management of the home. The sample of records seen held assessments from other agencies and or the home. The home also requests initial referral and assessment of needs information from the referring agency; social care and housing or the health authority/hospital. The majority of the The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 9 residents are local older people who are no longer able to live in the local community. The home has a variation to the registration category for four named persons that have been diagnosed with dementia care needs. Staff have received training in this aspect of care needs and care plans address the specific needs of individual residents. One of the residents who entered the home directly from hospital said they did not receive any information about the home but did not find that a problem as they already had a relative living at the home and so knew what it had to offer. Other resident’s were unable to recall what information had been provided. The home does have an admission procedure with information available to prospective residents and their families. They are invited to visit the home and take a look around and meet staff and residents. The home does have a letter format to issue to prospective Residents or their Relative/advocate to give confirmation in writing that the Home is able to meet the Resident’s assessed care needs. As yet the use of the form has not been implemented due to limited number of new admissions. However this will be introduced. The home does not provide intermediate care for residents referred solely for support and help to maximise their independence and return home. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. The Care Plan is thorough and is used by staff to meet the resident’s assessed care needs. Staff relate to residents in a friendly and respectful manner. The storage and administration medication must be monitored by management to ensure good practice and the well being of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of the resident’s files were seen and all held comprehensive care plans. The files have been restructured with dividers but there was no index or contents list. The files do have identification photographs in the care plans of each resident. Care plans are developed from a comprehensive range of assessments including: Behaviour, Nutrition, Mental health, Tissue Viability, Oral and Physical Health. Risk Assessments are completed in respect of the following: Personal Risk, Falls Risk and Mental Health Risk. Other records kept include: Medical History, Weight Chart, Personal Profile and Daily routines. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 11 The Home operates a key worker system and staff spoken with had a clear knowledge and understanding of the care plan and care needs of the resident’s. Staff had a genuine interest and insight into the resident’s background and family relationships. As key workers staff described in detail the daily routines and preferences of individual residents. The health care needs of each resident are recorded and monitored daily by staff and any changes are noted and passed on to staff at the time of shift handover. If there are any significant changes in health the appropriate health service is accessed and relatives are informed. There is a chronological record of visits to the GP and any appointments or treatment. The management had provided identification photographs with the medicines administration record (MAR sheet) for all resident’s, this improves the safe administration of medication. The inspector did observe administration of medication and check the records. It was found that although management and staff have completed training and know safe practice procedures there was evidence of some poor practice in respect of the recording of medication. This potentially can place residents at serious risk and was discussed with the deputy manager whose own practice must be improved to set the example for all staff. The systems and process must then be regularly monitored by management to identify and address any shortfalls in practice. The medication is stored in several different locations, a medication trolley, a medication fridge and stock of medication. The fridge is currently stored in the kitchen and was found unlocked at the time of the visit. It would be preferable if all of these were stored in a sole purpose, lockable room and consideration should be given to this with the new development plans for the premises. Storage of medication could be improved to ensure it is made secure and hygienic. All of the residents were assisted by staff to complete feedback questionnaires and the majority stated they were very happy with the care and services provided. This comment or similar was also stated by residents who spoke to the inspector during the inspection visit. Staff are considerate of the resident’s privacy and dignity. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. The Home provides a range of activities and leisure opportunities that reflect individual interests and group preferences. Relatives and friends are encouraged to visit and join in with the events held in the home and residents are encouraged to maintain involvement in the local community extend their social contacts and experiences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s files record individual interests and hobbies and a personal profile gives some background information of each resident’s skills and abilities and something of their character and personality. Staff spoken with were key workers for residents and were able to describe the particular daily routine of residents and their likely choices and preferences and whether there had been any changes since their admission to the home. Staff also knew of the family relationships and significant events such as birthdays and visiting arrangements. Two of the residents were 100 yrs old and others spoke of birthday parties at the home and cakes made by the cook to celebrate. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 13 Some of the residents spoken with enjoyed friendships with others in the home and would plan an activity together such as board games, dominoes and bagatelle. Others are able to pursue their own interests or go out and visit relatives. There is 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, Botanical Gardens and regular attendance at the Home of visiting singers/ entertainers, art and crafts sessions, quizzes, reminiscence sessions. The home encourages residents to maintain their independent living skills and opportunities and Personal Choice agreements are completed and risk assessments to ensure every effort is made to support residents in their preferred daily lifestyle. Daily records and the home’s systems detail where residents are consulted and permissions sought for various matters such as consent to change rooms, care provided by carer of a different gender and agreements to care plans and assessments. More generally staff use the residents preferred choice of name and were heard to checkout personal preferences and explain daily routines and what was being planned to increase individual’s choice and control over daily events. There had been a change in the kitchen with a new cook employed; There are four kitchen staff altogether three cooks covering 46 hrs and also a kitchen assistant covering 20 hrs. Menus were seen and provide a choice of a variety of meals and deserts. On the day of inspection residents enjoyed a choice of Beef stew or fish with potatoes and vegetables. Residents were happy with the meals provided and felt able to speak with the cook if they had some preferences. There are number of improvements that can be made in the kitchen to ensure the safety and hygiene in the kitchen is efficiently and effectively maintained these are listed in the statutory requirements. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The home must review its practice in respect of seeking and recording resident’s and relative’s views and suggestions. There was no evidence of any concerns or complaints being recorded. The home does have policy and procedures for Adult Protection and staff receive training and demonstrate an awareness of the issues for safeguarding the wellbeing and welfare of those living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Complaints policy and procedure in place and residents indicate on their feedback forms that they are aware of it and have not wished to make any complaints. Management and staff state that they will try to be responsive to the residents if any concerns are raised for example menus and particular dishes, laundry items and choice of activities. Staff will where possible address matters or take them to someone more senior if they feel unable to sort it out themselves. The inspector discussed the recording of complaints with the deputy manager and advised that all concerns, complaints and compliments should be recorded and actions taken to demonstrate that the home listens and will take action on matters that concern residents and their relatives. The last recorded complaint was made in 15.11.05. The The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 15 inspector was pleased to note there were one or two thank you cards displayed on the notice board. The home has Adult Protection policy and procedures; these were last reviewed on 31.10.06. The staff completed Adult Protection training in January 2006. Staff spoken with demonstrated an understanding of the issues relating to safeguarding adults and residents confirmed that they felt safe and respected by staff in the home. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 16 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 and 26 Quality in this outcome area is adequate. There has been no progress in making the proposed improvements to the home. This means that surroundings are in need of maintenance, repair and or replacement in order to achieve a safe, well-maintained environment that is comfortable and pleasant for those living at and visiting the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was made and the inspector did find there were a number of items to be addressed many of which are planned to be done at the time of the development and improvement works to the home. Progress with these plans was discussed and the provider is waiting on confirmation for works to proceed, it is expected this will take four / five weeks. It was agreed The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 17 the matters to be addressed would be listed and monitored at the next inspection. The issues related to equipment and machinery that was no longer in working order, awaiting repair or to be removed. Some items were unused and their purpose unknown and were stored inappropriately making areas unnecessarily cluttered and untidy. This is particularly important in the kitchen and laundry areas for example an ironing board was stored uncovered at the back of a washing machine and was covered in lint and dust. The kitchen presented some health and safety risks with holes in the wall structure above the gas oven burners and a fire blanket that was unusable in its wall mounted position. It is proposed to refurbish the kitchen with a new layout and furnishings. However in the meantime it must be made and maintained safe and hygienic. The inspector stayed in the home until early evening after dusk. The lighting throughout the home seemed quite dull and this gave particular concern in the lounges where a third of the light bulbs on the fittings needed replacing and residents were struggling to read books and newspapers. Similarly in individual bedrooms some of the light fittings by beds or above sinks needed bulbs replacing and this is important for health and safety of those who may need to get up in the night or need adequate light for reading in their rooms. The home plans to up date the call system throughout the home at the time of making improvements. However one of the resident’s rooms needed to be given priority due to a faulty call bell point and all others should be audited to ensure residents are able to call for assistance as they need it. Some areas needed a deep cleanse and a cleaning schedule should be set up and monitored by the manager to make sure that all aspects of hygiene and infection control are being done. This is particularly important for storage facilities for medication. Domestic staff need to have the appropriate tools and equipment to enable them to efficient in their work and to meet their health and safety requirements. Some items such as lampshades for naked light bulbs or mirrors are worn and unserviceable and need replacing. It is particularly important that an audit of all beds in the home is made and where necessary in consultation with the resident new beds are provided. Some of the bed linen seen looked worn and faded and in need of replacement. The exterior of the home needs some general maintenance work in terms of guttering, cleaning windows and keeping areas clear of litter from passing public. The frontage and rear areas would benefit from garden maintenance and some attractive shrubbery or planting. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 18 The home has replaced the top loader washing machine with two new washing machines. One is a model, which can wash at appropriate water temperature i.e. 65 degrees Celsius for not less than 10 minutes and includes a display to confirm this temperature. The second smaller one is out of order there have been no plans to repair this until the laundry is re-sited in the cellar. The rotary iron has a faulty part on the top and must be repaired to make sure it is safe for use. There is an ironing board but staff and management state this is never used. There has been no work done, to improve the laundry walls and to make them readily cleanable and so that cleaning can be undertaken around and behind the machines, due to plans to re-site and improve the laundry facilities. Some maintenance and decoration work has been done with all of the individual bedrooms that will not be altered have been decorated and in the communal areas the carpets have been cleaned. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. There have been a considerable number of changes of care and ancillary staff at the home. There are a sufficient number of staff on duty to meet minimum requirements however changes in the number of residents or the level of needs of the residents would need an increase in staffing levels to ensure the needs of the residents can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One of the relatives stated “I am completely satisfied with the care and consideration given by staff on duty. But I do feel that having only 3 staff on duty from 3.00 pm to 10.00 pm and only 2 on duty at night is not enough.” This comment highlights concerns that if there were any emergencies and the range of tasks and duties to be done by care staff in the afternoon and evenings this leaves very little time to devote directly to the residents. This issue was raised with the provider at the time of the inspection who stated that at the present time given the care needs of the residents the staffing levels meet the ratio’s recommended by the Department of Health. Staffing levels would be reviewed should the number of residents or their care needs increase. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 20 The owner / provider and the area manager provide management cover at the home as needed. There is one deputy manager (currently deputising for the manager’s vacancy), 6 senior care staff, 8 care assistants, 4 night care, 2 cooks (1 on maternity leave not returning), 1 breakfast cook, 1 kitchen assistant, 2 cleaners (5days / 2 days 9.00 – 12.00) and 1 laundry staff (7 days per week 9.00 – 12.00). Staff duty rotas seen for 15.01.07 – 21.01.07. These do not record the dates and times that the provider or area manager spend on site fulfilling management duties. There are currently no care staff vacancies with nineteen care staff of which thirteen have NVQ level 2 qualification providing more than 50 of the staff qualified. The ancillary staff also completing the relevant training and qualifications; the cook is enrolling on NVQ level 1 in catering and hospitality. A sample of staff files were seen, these were generally well organised with a file contents and audit list indicating files are monitored and shortfalls in references etc addressed. The staff references and CRB reference were held and processed appropriately. Job descriptions, terms and conditions/contracts were held on file and staff are issued with a staff handbook. There is also a format for equal opportunities in employment monitoring information. There was evidence of staff training events and the pre inspection information listed the following course being attended during the past inspection year: Aset Dementia Course, Protection of Vulnerable Adults, Dementia Awareness and Health and Safety. There is further training in safe working topics planned during the spring of 2007 including Basic Food Hygiene, First Aid and Fire training. It was not clear how many staff or which staff had attended training. Records did not show evidence of a training and development programme for staff. The company does value staff training and development and staff files held records of induction and staff appraisals, the latter are completed six monthly, the last interviews were held in November 2006. Seven staff are listed as trained for administration of medication: the majority of these are senior carers and the deputy manager. The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This is a significant period of change for the Home in terms of senior management, the premises and ultimately the statement of purpose for the home. The Home generally is well established in the local community and has good systems and policy and procedures in place. The ethos is to strive to improve the facilities and services available to meet the needs of residents. The management team must ensure that minimum standards are maintained throughout to safeguard the health and safety of the residents, visitors and staff at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 22 The registered manager Yvonne Lavender resigned from her post for new employment in October 2006. Since that time the provider and the company area manager have provided support to the deputy manager who is deputising as manager in the interim period. The post has been advertised and it is hoped to appoint a suitable candidate. It is proposed that the deputy manager would take a lead on the new development of a specialist Dementia Care provision within the home. In the meantime the deputy manager works a couple of days in management duties and the rest of her days as deputy manager on the shift rotas. The deputy manager provides the on call cover at all times. Staff confirm that they feel well supported and able to approach the management team with any concerns. The deputy manager has done well to maintain the morale of the staff group and the standards in the home during a period of change and development. In the absence of a registered manager the provider must ensure there is regular monthly monitoring of the systems and records in the home. There is some evidence that this has been done and that systems are in place to do this. It is especially important that care practice is monitored and such practice as medication administration, cleaning records and accident records etc. Any shortfalls or patterns identified would then be addressed to ensure that good standards of practice are maintained. A sample of residents records in respect of savings and monies held were inspected. These were in good order however recording could be improved to note outgoings and balance at each entry. The home does not act as appointee for any of the residents. One of the residents manage their own finances while relatives and representatives manage for other residents. The management provide regular staff meetings and seniors meetings to provide information and support to staff. There are staff appraisal interviews held twice a year however there was no evidence of regular supervision sessions for care staff. The deputy manager said that staff will come to speak with her if there is an issue or concern and similarly she will ask to see staff however this should be formalised with regular supervision. The list of maintenance and associated records provided in the pre inspection information was comprehensive and current. All safe working topics appear to be addressed and appropriate checks and certificates updated. The Fire Officer’s last visit was made on 16th December 2006 and Environmental Health on 19th December 2005. The health and safety department inspector visited in March 2006. The home will request follow up visits once the proposed works have been completed. Staff receive training in safe working practice topics and were aware of action to be taken in the event of an emergency. During a tour of the premises it was noted that a few maintenance issues need to be addressed to ensure the health and safety of residents however the senior management gave The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 23 assurances that these would be met through the development programme planned. Some items could be addressed more immediately through effective monitoring and reporting processes such as:Refill laundry first aid box. The home does complete risk assessments for a wide range of topics however none had been seen for the use of bedrails. This was of particular concern in one resident room (No 5) where the bed base was torn and worn. The staff stated this would be agreed and recorded as part of the care plan. The Bush DS0000064824.V348250.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 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 2 X 2 X 2 2 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 2 X 2 X 3 2 X 2 The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 25 YES 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 OP4 Regulation 14 (d) 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. Timescale of 30/04/06 has not been met. The registered person and the registered manager must review and monitor staff administration of medication procedures and records to ensure good practice and protect the well being of residents. 9 Clean the medication fridge and seal 9 The registered person and the registered manager must: Clear guttering of debris and foliage 19.2 Monitor damp stains on corner wall above sink in Room 29. 19.2 The registered person and the registered manager must: Provide bin lid in the kitchen 19.2 Clean the fly grill covering the DS0000064824.V348250.R01.S.doc Timescale for action 31/01/07 2. OP9 13 (2) 31/01/07 3. 4. OP9 OP19 13 (2) 23 26/01/07 28/02/07 5. OP19 23 28/02/07 The Bush Version 5.2 Page 26 6. OP19 23 7. OP19 23 kitchen window 19.2 Remove the unused first Aid cupboard from the kitchen 19.2 Deep cleanse of the kitchen floor and wall border edges 19.2 Store the potatoes off the floor 19.2 31/03/07 The registered person and the registered manager must: Remove or repair the dishwasher 19.2 Seal off the two holes in the metal splash board at the back of the kitchen cooker 19.2 28/02/07 The registered person and the registered manager must Resite the fire blanket higher on the wall to make it effective for safe use 19.5 Tidy and clear the small hallway at the top of the stairs that lead to and from the cellar providing a fire exit route. 19.5 The registered person and the registered manager must: Deep clean the small dining room carpet Deep clean the carpet in Room Repair or replace carpet cleaner. Remove broken upright hoover or repair for use. Replace rusted cleaners trolley with suitable for purpose trolley. Remove surplus trolley from cleaners cupboard. 19.2 Provide new mirror in downstairs bathroom. 19.2 Provide lampshade for bare light bulb in front of lift on first floor. 19 The Responsible person must DS0000064824.V348250.R01.S.doc 8. OP19 23 31/03/07 9. The Bush OP19 23.- 31/03/07 Page 27 Version 5.2 (2)(b)(d) 10. OP19 23 11. OP20 23 12. OP20 23 provide the CSCI with a refurbishment/redecoration plan, together with a programme for the commencement and completion of all necessary works. The registered person and the 30/04/07 registered manager must ensure all parts of the Fire Officer’s report of 15.12.05 are completed. 19.5 28/02/07 The registered person and the registered manager must provide suitable lighting in all areas including the following: the lounge areas individual bedrooms downstairs bathroom 20.6 31/03/07 The registered person must improve the hairdressing facilities for service users and these must remain smoke free. 20.2 30/04/07 Repair and or replace buzzer board and call points to ensure there is an accessible and effective call system throughout the home. Particular priority attention to be given to Room 9. 22.8 31/03/07 The registered person and the registered manager must provide a new bed in Room 5 and review condition of all other beds in the home. 24.2 The registered manager must remove the television set stored on the resident’s armchair in Room 9 24.1 31/03/07 The registered person must ensure: All windows are kept clean. 25.1 DS0000064824.V348250.R01.S.doc Version 5.2 Page 28 13. OP22 16,23 14. OP24 23 15. OP25 23 The Bush 16. 17. 18. OP26 OP26 OP26 12,16 16 (2)(j) 16(2)(j) 19. 20. OP26 OP26 16(2)(j) 16(2)(j) 23(2b)(d) 21. OP30 18 22. 23. OP31 OP33 9 24 Remove Top Loader washing machine from the laundry 26.1 Repair rotary iron. 26.1 Repair or remove out of order washing machine 26.1 Remove items of unused machinery / equipment that are stored in the laundry. 26.1 Clean the ironing board and replace ironing board cover and find suitable storage place. 26.1 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. The registered manager must develop and provide a training and development programme for staff. 30 The registered person must appoint a registered manager for the home. 31 The registered manager must provide and maintain regular monthly monitoring of the systems and records in the home. 33 The registered manager must ensure all staff receive supervision at least six times a year. Refill laundry first aid box 38.2 The registered manager must ensure there are individual risk assessments for the use of DS0000064824.V348250.R01.S.doc 31/03/07 31/03/07 31/03/07 20/01/07 31/03/07 30/04/07 31/03/07 31/03/07 24. OP36 18 31/03/07 25. 26. OP38 OP38 13 13 28/02/07 28/02/07 The Bush Version 5.2 Page 29 bedrails. 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. Refer to Standard OP16 OP20 OP24 OP36 OP37 Good Practice Recommendations Ensure all concerns, complaints and compliments are recorded. Review staff smoking arrangements to ensure resident’s hairdressing area is kept free of cigarette smoke. 20.2 Provide new bed linen to replace worn and faded linen. 24.2 Issue staff with keys for the staff lockers. 36.1 Provide file index and audit system with numbered/named dividers for all resident’s files. 37.3 The Bush DS0000064824.V348250.R01.S.doc Version 5.2 Page 30 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: 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. 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