Inspection on 22/01/08 for The Bush

This inspection was carried out on 22nd January 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Bush 04/03/09

The Bush 24/07/07

The Bush 19/01/07

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 Joy Hoelzel Key Unannounced Inspection 22nd January 2008 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.V355729.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.V355729.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 Vacant post Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places The Bush DS0000064824.V355729.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. 24th July 2007 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’. Currently the home does not have a registered manager in post. 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 amenities. The accommodation comprises of 30 single and 7 double occupancy bedrooms over two storeys, with a shaft lift to facilitate access between floors. There are no en-suite facilities. Communal facilities include a large lounge, a large dining area, a small lounge, a small dining room and a conservatory. A garden area at the rear of the property is accessible to people using the service. A car parking area is available at the front of the building. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents can be obtained from the home. The service user guide does not include information on the current level of fees for the service. The reader may wish to obtain more up to date information from the care service. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours on Tuesday 22nd January 2008. It was conducted by the Commission for Social Care Inspection (CSCI) regulation inspector and the pharmacy inspector. Twenty three of the thirty-eight National Minimum Standards for Care Homes for Older People were inspected as they are viewed as key standards for services. Twenty one people are currently living at the home and during the inspection were observed to be accessing areas around the home. The acting manager was on the premises supported by five care staff, and ancillary personnel. The area manager of the company arrived at the home during the morning of the inspection. The acting manager will be leaving the home at the beginning of February, the area manager will be working in a managerial capacity until a suitable person has been recruited for the registered managers position. The care provided for four people was examined in detail, relevant documents were inspected, discussions were held with people living at the home, visitors, members of staff and the acting manager. Observation was made of the various daily activities and a tour of the premises was conducted. A full audit and inspection of the medication procedures was conducted by the pharmacy inspector the findings of which are included in this report. What the service does well: People living at the home are generally satisfied with the care provided and the amount of support they receive. ‘The food and staff very good’ ‘I am very happy at the home I have been a resident for X number of years my bedroom is comfortable and meals are very good’. Staff training in the core and specialist topic areas continues to be arranged with 50 of the care staff team accredited with National Vocational Qualification in care. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 6 Generally the administration of medication procedure is satisfactory, however some amendments to working practice are required to ensure the home has a safe and reliable system. 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 summary of this inspection report can The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 8 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.V355729.R01.S.doc Version 5.2 Page 9 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): OP 1,3,6. Quality in this outcome area is adequate. The service has developed a statement of purpose, which sets out the aims and objectives of the home, and includes a service user’s guide, which provides basic information about the service. The guide is made available to individuals in a standard format. The home has procedures in place for assessing the needs of people who may wish to consider moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has produced a statement of purpose and service user guide offering information about the service provision. Both documents are available at the home and have been reviewed in June and July 2007 respectively. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 10 The documents were looked at after this inspection and found that some of the information included in them and the findings of this inspection did not correspond. The statement of purpose indicates that a lockable bedside cabinet is provided in all bedrooms for the safe storage of personal possessions. During the tour of the premises not all rooms seen had a lockable drawer or space. The document refers to a different establishment and outlines the specifications of the home, and that ‘the vast majority of bedrooms have en suite facilities’. None of the bedrooms has this facility. The previous regulatory body (NCSC) is referred to as the point of contact when a person wishes to make a complaint. To ensure people have the correct information regarding the service both documents will need to be reviewed and revised. The service user guide does not include information on the current level of fees for the service. The case file of the person who recently moved into the home contains preadmission information from the local Primary Care Trust and a community care review. An initial care plan was developed from this information at the point of moving into the home. The home does not offer an intermediate care service. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 11 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): OP 7,8,9,10 Quality in this outcome area is adequate. Each individual has a care plan that includes the basic information necessary to deliver the resident’s care but generally is not detailed or person centred. Some omissions of important information may place people at risk of not having their care needs fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people living at the home have a case file, which includes risk and healthcare assessments, a plan of care is developed as soon after admission to the home as practicably possible. Four case files were selected for inspection and generally contained information of an individuals assessed care needs. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 12 Since the inspection in July 2007 a care plan has been developed for the personal care and hygiene needs of each individual, this gives staff the information required to ensure health care needs are fully met. Other care plans for other areas of need must be as informative. There is evidence to suggest that people and/or their representative are involved in the care planning process, each of the four case files looked at contained a signed document indicating participation. The manager reviews the plans on a monthly basis but occasionally there is a lack of recording the latest information when a change of need is identified. One case file recorded that there is a potential problem of a person developing pressure areas due to a frail physical condition; a care plan has not been developed to ensure that staff have the relevant details of the interventions and actions needed to reduce this risk. Another case file suggested a food supplement was to be offered daily, there was no record to confirm that this had been offered and on discussion with the acting manager the recorded information was incorrect as this had been discontinued when an alternative supplement was prescribed. One care plan recorded a multi agency decision for special restrictions for a person to ensure that their safety is upheld; the acting manager discussed the arrangements for maintaining their contact with a local community group each week. The pharmacist inspector also visited the home on the 22nd January 2008 as part of the key inspection and carried out an inspection of the medicines management systems being practiced within the home. The pharmacy inspection looked at the effectiveness of the home’s arrangements for the receipt, recording, handling, storage, safekeeping, safe administration, and disposal of all medicines received into the home. The inspection comprised of examining the medication storage area, examining the records kept and having discussions with both the care staff and residents. The findings of the inspection were then fed back at the end of the visit. We found that there was a good system in place for the ordering of the residents’ medication and for recording the receipt of it into the home. We found that medication held over from the previous month was also being taken into account to give a grand total for the start of the new monthly cycle. With these accurate figures in place the audit trails conducted during the inspection found that on the whole the residents tablets and/or capsules were being administered as instructed by their doctors. The exception to this appeared to be with the administration of the liquid medication and in particular the The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 13 administration of small unusual quantities. The management team agreed to examine the reasoning for this. We found that the medicine administration records (MAR) were also of a fairly good standard with no gaps found on the current charts and abbreviations were being used to explain the reasons for medicines not being administered. A small number of issues were however identified and these included a) where variable doses had been prescribed the records did not show what quantity had been given b) with “as directed” medicines the home had handwritten some clearer directions on to the MAR charts but there was no clear evidence from the prescriber to support the administrations being undertaken by the home. There was also no additional information in place for the administration of “when required” medicines, particularly those being used to calm residents down. The lunchtime medication round was observed and many aspects of the procedure were carried out well. Some issues however were identified and these included the carrying of medicines around the home in medication pots and the poor techniques with administering inhalers and eye drops. Concerns were also expressed about the length of time antibiotic eye drops were being administered; normally these types of eye drops are only administered for a period of between five to seven days. We found a number of the residents were self-administering part of their prescribed medication. We found that the home had not carried out any risk assessments to determine a) whether the residents had the capability to manage their own medication b) what support the residents might need to continue with their independence. There was also no evidence that the home was monitoring the residents’ compliance to administer their medication as stipulated. We also found that this medication was not being kept secure by the residents and therefore posed a risk to other residents in the home. We found on the subject of storage and handling that the two trolleys were over capacitated with both current and excess medicines being stored in them. This meant that the trolley were not well organised and there was no provision for the storage of medicines in the event that the population in the home increased. The home had a fridge, which was dedicated to the storing of the residents medication. We found that the maximum and minimum temperatures were not being monitored on a daily basis, even though a maximum and minimum thermometer was present. On the day of the inspection the The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 14 minimum reading on the thermometer was measured at 1°C and as a consequence the home was asked to remove and discard the insulin present and obtain a new supply. The home had a Controlled Drugs cabinet, which appeared to have been attached to the wall using the correct fixings. The location of the cabinet, being in the dining room, was however a concern and potentially left any Controlled Drugs stored inside vulnerable in terms of security. The home had a Controlled Drugs register but had not recently used it because the home had not had any Controlled Drugs on the premises since January 2007. Staff were observed to be addressing people in a polite and dignified way and were observed to be carrying out interventions in a competent manner. Two care staff demonstrated good techniques of using the hoist when transferring a person from a wheel chair to an armchair, the procedure was explained prior to beginning the move and the person was offered an assurance during the process. Most people were well dressed and during the time of the inspection it was evident that good relationships had been developed and maintained with the staff. Three people stated that the staff ‘ were very good’. The Bush DS0000064824.V355729.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): OP 12,13,14,15 Quality in this outcome area is adequate. The home tries to be flexible and attempts to provide a service that is as individual as possible and generally staff are aware of the need to support residents with social, recreational and leisure activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does not have a social activity coordinator, the acting manager explained that care staff arrange the activities in addition to their care duties. An entertainer is arranged to visit the home each month, progressive mobility sessions are held weekly and the occasional pub lunch is arranged. The acting manager discussed the reluctance for the service users to participate in any arranged activity. During the morning people were observed in a variety of activity, some people were in the lounge areas watching the television, others remained in their The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 16 bedrooms, and two people went out for the morning. Later on a member of the care staff was encouraging people to play Hoop-la, those participating appear to be enjoying it. One person stated that he was able to go out independently to the local shops and enjoyed this, another gentleman was painting model airplanes and trains and said he enjoyed this as ‘it helped to pass the time’. One person stated that they passed the time by talking to other people and went on to say that they were ‘satisfied with the arrangements’. They went on to say that they would like, occasionally, to go to the local pub and have ‘half a pint’. One person was receiving a visitor that they hadn’t seen for a while and was catching up on family news and talking of ‘the good old days’. Another person who had been resident for a period of time stated ‘Very happy at the home very satisfied, bedroom comfortable and meals very good’. People are supported with maintaining their cultural and religious interests, with arrangements for religious observance arranged in the home and in the community. The home operates a four weekly rotational menu offering a choice of two main and dessert courses. Alternatives are provided if the menu is not to a person’s preference. The midday meal looked well presented, appetising and nutritious, people stated that the food is good. Staff were observed to be asking people what they would like for their dinner during the morning of this inspection. A member of care staff was observed to be assisting a person with their meal in a discreet and sensitive way. The Bush DS0000064824.V355729.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): OP 16,18 Quality in this outcome area is adequate. The service has a complaints procedure that is displayed on a notice board in the home; some amendments are required to ensure that all contact details are correct. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaint procedure that is included in the statement of purpose and service user guide and is displayed on notice boards around the home. The contact details of CSCI should be included in all documents relating to making a complaint (some documents continue to have the previous regulatory body, NCSC, as a point of contact). One person stated that they would speak first with their family if they had any problems and concerns and then the family member would then speak with the staff, but at this moment in time they had ‘no worries’. The acting manager discussed the recent concerns raised at the home where the multi agency safeguarding adults team was contacted for advice on how to The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 18 proceed with the concern. Following the advice given, the home investigated the concerns using their own procedures resulting in a satisfactory conclusion. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this have been maintained and fully receipted The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 19 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): OP 19,22,24,26 Quality in this outcome area is poor. The physical environment remains at a very poor standard and requires substantial capital expenditure to bring the home up to a reasonable level. There are several areas that continue to place people at potential risk of injury or harm and people are having to ‘make do’ with a standardised and poor environment in which to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the inspection in July 2007 some decoration has taken place in that the main lounge has been decorated, the armchairs have been replaced and some dining chairs in the large dining area have been purchased. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 20 However during the tour of the premises it is very evident that considerable expenditure is required to fully redecorate and refurbish both the communal and private areas, to bring the home to the required standards and to improve the standards of living for the people in residence. The main kitchen and laundry areas are in desperate need for a full refit. A telephone conversation with the owner of the home, during the inspection, offered some assurance that plans have been made for all areas to receive attention within the very near future and being fully completed within six months. ‘ Plan to extend the conservatory to include adequate heating, additional lighting with spotlights in problem areas. Refurbishment of all bedrooms communal toilets and bathrooms we are meeting with the builders tomorrow to discuss the schedule of works. Décor and bedroom furniture has been looked into, all homework done’. The owner additionally offered an assurance that a schedule of the plan of works would be forwarded to us by 28/29th January 2008. The plan was received on 29th January 2008 and gives a schedule of the work, with the decoration of the bedrooms, lounge and dining areas to commence 4th February 2008. The plan to extend the conservatory, refit all bathrooms and completely refurbish the laundry will be started by the end of February 2008. The plan does not include definitive dates or the schedule of the works or how it will impact on the current residents. The plan does not include any works to the main kitchen. During the tour of the premises some bedrails fitted to beds were incompatible with the bed type, this was discussed with the acting manager and area manager and immediate attention was given to ensuring all rails in use were suitable for the bed on which they are used. A copy of the department of Health Device bulletin for the safe use of bedrails was given to the acting manager for reference. The home continues to place people at risk in the case of an emergency with the use of wooden wedges to keep doors open. Where there is a need or a personal preference for doors to be kept open then appropriate door closures must be fitted, that are linked with the fire alarm system and close when the alarm is activated. Not all areas where personal care is undertaken have been supplied with suitable hand wash facilities at the point of the delivery of care for the effective control of infections. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 21 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): OP 27,28,29,30 Quality in this outcome area is adequate. People are generally satisfied that the care they receive to meet their needs, and there appears to be sufficient staff to meet the health and welfare of people currently using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A rota is maintained to show which staff are on duty at any given time of the day or night. During the morning of the inspection the acting manager was supported by three care staff, with catering and domestic staff additional. The area manager arrived at the home during the morning to offer her support. Twenty-one people are currently residing at the home. The acting manager stated that staffing levels are maintained as 8am-4pm 1 manager 1 senior care staff, 2 care staff, 3pm-10pm 1 senior care and 2 care staff, The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 22 Nights- 2 care staff with a nominated person on call for emergencies. During this inspection all people looked well cared for and although the staff were obviously busy there did not appear to be any delay when assistance was required. People commented that the staff were ‘very good’ and that they had no particular concerns and were generally satisfied with the care they received. The acting manager stated that training in National Vocational Qualification Level 2& 3 are ongoing for staff. One staff member discussed the training and stated that she was enjoying it and felt supported by the acting manager. Three staff personnel files were looked at and evidenced that appropriate checks are carried out before starting to work at the home. Certificates and accreditations for training are kept in the files. It was difficult to establish the training identified or completed by each individual as no matrix is maintained. For ease of reference it was recommended that this be developed for the plan of training for 2008/09. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 23 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): OP 31,33,35,38. Quality in this outcome area is adequate. The management team have an understanding of what is required for improving the home and for ensuring the health, safety and welfare of people living, working and visiting the home are upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has continued to operate without a registered person as manager since October 2006; Mrs Yvonne Ireland has been in the acting manager The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 24 position for a considerable period of time and has been supported by Ms Christine Price the area manager of the company. Mrs Ireland has offered her resignation from the position with a planned leaving date 1st February 2008. Ms Price will then manage the home until a suitable replacement can be recruited. Throughout this inspection Mrs Ireland and Ms Price demonstrated a good knowledge of the current resident group and the dilemmas encountered with the ageing process. Quality assurance and monitoring systems are not in place to ensure that home is meeting its stated aims and objectives and statement of purpose. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this have been maintained and fully receipted. Documents were seen for the routine weekly, monthly and annual safety checks (fire alarms, hot water, etc). However as detailed earlier in this report there are some outstanding health and safety issues that need to be addressed e.g. fire safety, safe use of bed rails and infection control measures. Since the last inspection the acting manager has developed an evacuation plan with an agreement with a nearby home for accommodation in the event of an emergency. The fire risk assessment for the premises is due for a review at the end of January 2008. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 25 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 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 X X X X X X 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 1 X 3 X X 2 The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Requirement Appropriate information relating to medication must be kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including “as directed”, “when required” and self administered medication so that all medication is administered safely, correctly and as intended by the prescriber, to meet individual health needs. Staff who administer medication must be trained and competent and their practice must follow current written policies and procedures to ensure that residents receive their medication safely and correctly. Medication must be stored within the temperature range recommended by the manufacturer to ensure that medication does not loose potency or become contaminated. The proposed plan for the complete refurbishment and DS0000064824.V355729.R01.S.doc Timescale for action 22/02/08 2 OP9 13(2) 22/02/08 3 OP9 13(2) 22/02/08 4 OP19 23(2) 02/08/08 The Bush Version 5.2 Page 27 5 OP26 23(2) redecoration of the home (as supplied by the responsible individual) must be completed within the given timeframe. To ensure a suitable, clean and safe environment is provided for people living at the home. The plan for the complete refurbishment of the laundry (as supplied by the responsible individual) must be completed within the given timeframe. 02/08/08 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 Refer to Standard OP1 OP7 Good Practice Recommendations The statement of purpose and service user guide should be reviewed and revised to ensure that the information in the documents reflects the actual service provision. The care plan should be updated and revised when a change of need has been identified to ensure all care needs can be fully met. Following assessments where a need or risk has been identified a plan of care should be developed to ensure that staff have sufficient details to fully meet that need or to reduce the risk. Social, leisure and recreational activities should continue to be arranged suitable to the individual preferences of the people living at the home. The complaint procedure should be amended to include the current contact details of CSCI. Suitable hand wash facilities should be available in all communal areas and at the point of the delivery of care for general hygiene and for the effective control of infections. Recruitment for a suitable person for the registered managers position should be given priority. For ease of reference it was recommended that a matrix be developed for the plan of training for 2008/09. Health and safety maintenance checks should be carried DS0000064824.V355729.R01.S.doc Version 5.2 Page 28 OP8 4 5 6 7 7 8 The Bush OP12 OP16 OP26 OP31 OP30 OP38 out for all systems and equipment in use and records kept of the checks and any action that may be required. The Bush DS0000064824.V355729.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 77 Paradise Circus Queensway Birmingham B1 2DT 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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