Inspection on 02/05/07 for Cardinal Heenan House

This inspection was carried out on 2nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Cardinal Heenan House 25/08/09

Cardinal Heenan House 01/02/06

Cardinal Heenan House 11/05/05

Cardinal Heenan House 11/10/04

Cardinal Heenan House 13/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cardinal Heenan House Don Orione Centre School Lane Roby Mill, Upholland Lancashire WN8 0QR Lead Inspector Mrs Gwen Miller Unannounced Inspection 10:00 2nd May 2007 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 Cardinal Heenan House DS0000005890.V331866.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. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cardinal Heenan House Address Don Orione Centre School Lane Roby Mill, Upholland Lancashire WN8 0QR 01695 622885 01695 627609 upholland@hotmail.com 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) Sons of Divine Providence Mr Gerard Stewart Hilton Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 31 residents in the category of OP (old age, not falling within any other category). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 1st February 2006 Date of last inspection Brief Description of the Service: Cardinal Heenan House is owned by the Sons of Divine Providence, and their head office is based in London. Cardinal Heenan House is set in a rural area of Roby Mill, which is approximately one mile from the village of Upholland where a number of local community facilities can be accessed. Within the home there is a large entrance hall, with seating. The home also consists of a chapel, a large open plan dinning room, with access to ground floor bedrooms and the first floor. There are two lounges on the ground floor, and access to the outside seating area. There are two toilets and a bathroom with an assisted bath also on the ground floor. The first floor consists of bedrooms, two bathrooms, and a smoking room. There is also bedroom accommodation on the lower ground floor. In total there are 32 single rooms with en-suite facilities. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this home has been carried out over the period since the previous inspection January 2006. This is to give an overall picture of Cardinal Heenan House using evidence and information gathering, in the form of a pre inspection questionnaire, letters to and from the home during that period and comment cards from residents and relatives. The inspection also included a site visit to the home, which was completed in one day. It was unannounced, which means that the manager, staff and residents did not know it was to take place until the inspector arrived. On 2nd May 2007 (the day of this visit), 30 residents were accommodated at Cardinal Heenan House one resident was in hospital. The inspector spoke with residents, staff members, visiting relatives, a visiting GP, chiropodist, nurses and a representative from Boots chemist. 26 comment cards were received from residents and 22 from relatives, carers or advocates. Case tracking (whereby the inspector focuses on a small number of residents and examines their care, from admission to the present time) of three residents, was carried out. Part of the visit included looking at daily notes and information about the home and residents. Time was spent observing the workings of the home and how staff members supported residents. A good lunch was sampled and eaten in the company of three residents. The inspection included a tour of the premises. At the time of the visit, (02/05/07) the information given to the Commission for Social Care Inspection, showed that the fees for care at the home are from £359 to £369 per week, with added expenses for hairdressing and newspapers. What the service does well: In line with the home’s policies and procedures, Cardinal Heenan House tries to make sure that there is equal care given to all residents, considering their individual choices and preferences and giving equal support to all irrespective of their race, gender, disability, sexuality, age, religion or beliefs. There is equal consideration given to prospective employees and there are male and female staff between the ages of 18 and 65 years working at the home, training and development programmes are offered to all staff. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 6 Many of the staff have been employed at the home for a long time, which means they have got to know the residents very well. The home ensures that all residents have equal access to different parts of the home via a lift, aids and adaptations are in toilets and bathrooms and where individual residents need them. A loop system is installed to assist those with hearing problems. Cardinal Heenan House provides a friendly, informal atmosphere where dignity is acknowledged and independence is encouraged. Many relatives were keen to give their comments about the home, these included; “the care home feels like a family and treats the residents and relatives like they belong to them,” and “we feel comfortable around the home, to come and go at any time”. When discussing their visits to the home, relatives said “visitors are always made welcome with a smile, there are no restrictions, rules or regulations in place” and the home has an “exceptionally high standard”. 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 be made available in other formats on request. Cardinal Heenan House DS0000005890.V331866.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 Cardinal Heenan House DS0000005890.V331866.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): 1,2,3,&5. Quality in this outcome area is excellent. Good information is provided which allows people to make informed choices whether or not the home will meet their needs. Full assessments of needs are carried out for all residents to ensure the home can look after them properly and give the right sort of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home’s Statement of Purpose and Service User Guide contains all the relevant information needed for prospective residents to make an informed choice when they are considering Cardinal Heenan House as their home. Copies of the home’s information are placed on a table in the entrance to the home and the manager and staff welcome visitors to the home to have a look around and speak with other residents and staff. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 9 Many residents said they had spent a short stay at the home prior to making any decision about living there. Some said they had made their choice after quite a while and during this period they were classed as temporary residents, some said they had visited friends in the home which had influenced their own decision to make Cardinal Heenan House their home. Comment cards received, confirmed that written information about the home had also been received, prior to making any decision. Prospective residents undergo a full assessment of need, including their likes and dislikes, to ensure that Cardinal Heenan House will be the right place for them to live, and that the home can provide the right care for them. These assessments were seen during case tracking and were very detailed. Assessments are completed with the resident, other relevant agencies such as social workers or health professionals are included if needed. Residents case files seen during case tracking, contained written contracts between themselves and the provider, stating clearly what was and was not included in the cost of staying at Cardinal Heenan House, contracts also explained their rights as residents of the home. The pre inspection questionnaire showed that 11 residents were admitted to the home since the previous inspection. Cardinal Heenan House does not offer intermediate care. Cardinal Heenan House DS0000005890.V331866.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 &10. Quality in this outcome area is excellent. The health needs of residents are well met and people are treated with dignity and respect. The systems for the administration of medication are clear and comprehensive arrangements are in place to ensure resident’s medication needs are also met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Case tracking showed that good care plans are in place for each resident, such plans include action to be taken by staff in areas of health, personal and social care needs of each resident. These are reviewed regularly and completed with residents. Care plans were very detailed and provided a clear picture for all care staff of what the individual could achieve on their own, what tasks they required help in and what areas they could not manage at all. Dr C. was visiting one of his patients during this site visit, he spent time with the inspector and gave his very positive opinion of the home, this view was Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 11 also confirmed by the chiropodist, who added “there’s always plenty of staff around and they will always bring residents to the clinic.” A visiting nursing auxiliary said that “the home felt good and the home takes residents out and recognises the importance of making people feel at home”. District nurses visit on a daily basis and it was apparent that people are treated in their own rooms in order to ensure privacy and dignity. Visits by G.P. s, and district nurses are recorded and specialist advice from geriatricians, continence advisors and community psychiatric nurses, is sought when necessary, to meet the needs of the residents. Comments received from residents, included “the atmosphere is very welcoming and caring. Staff and residents get on well together, have a good time and appear to care for each other’s needs. Independence is encouraged.” Many written and verbal comments were received from relatives, these included “the home respects independence, maintains dignity, ensures nutrition and ensures cleanliness.” Another said “The home provides a good quality of care which is tailored to meet individual needs”. Resident’s may choose to administer their own medication, a locked facility is provided for this. The home’s storage and administration of medicines is appropriate and records seen were up to date. Residents said they felt their privacy is respected and their care is provided in a dignified manner. Staff were noted to knock on bedroom doors and seek permission before entering. Residents said they are always asked how they wish to be addressed, although most use first names as the norm. Residents have their own en-suite bedrooms, providing privacy and dignity. A portable public phone is available for residents although residents are welcome to use the office phone, in private. There is a loop system in the home to assist people who have a hearing impairment and some individuals have their own mobile phones. This helps to maintain and promote independence, choice and privacy for individuals. Cardinal Heenan House DS0000005890.V331866.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): 12,13,14,15. Quality in this outcome area is excellent. Religious and recreational needs are catered for, links with the community are particularly good, these support and enrich resident’s chosen lifestyle. The meals are good offering both choice and variety, whilst catering for special dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre inspection questionnaire confirmed that the home continues to offer a range of activities including; exercises, “pampering”, arts & crafts, board games, mobile library, mini-bus outings, shopping trips and “one to one” trips out. Most residents said they enjoyed the activities provided, and they enjoyed going out on trips. The notice boards in the home advertise various appropriate activities that are available along with any forthcoming events. There are residents meetings, where places of interest to visit are discussed. One resident has his own garden area. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 13 Many residents attend daily mass in the chapel, some said this was very important to them. Some residents are supported by ministers from other faiths, these are welcomed at the home. Comment from relatives, confirmed they are welcomed at the home at any time and always offered refreshments. They also added they are encouraged to spend as much time as possible with their relative or friend and encouraged to join in celebrations such as birthdays and festive activities. By talking with residents, it was clear that they are asked to make choices in what to eat, when to rise and retire, how to spend their time, how to furnish their room, who they wish to keep company with and who they nominate to manage their affairs (if they do not want to manage them themselves). They are also asked if they wish to manage their own medication (as mentioned previously) and given a choice of locking their bedroom doors. All residents spoken with said they chose what to do with their time, although they were encouraged to join in activities in a communal setting, their choice to remain in their own rooms or go out into the community, was acknowledged. One resident said “I like to colour, I like my own space sometimes, like to draw, don’t like going out for day trips”, although many residents said they had enjoyed a recent trips to Knowsley Park and Rivington Barn. Some residents choose to go for walks in the local area, some visit the nearby pub, this can be with staff or independently, according to ability of the individual resident. Cardinal Heenan House continues to provide a very good standard of food with a varied menu for all mealtimes. Samples of menus provided for this inspection showed a good choice of foods, residents spoke well of the choices, quality and quantity. Lunch was shared with three residents, one required assistance which was provided in a dignified and encouraging manner. Food served looked appetising and one visitor commented “the food always smells good”. The dining room was set out with matching table linen, crockery and fresh flowers on each table. There is plenty of room for all residents to eat at one sitting and room for their visitors too. Diabetic and vegetarian diets are catered for providing equality of choice for all residents. Cardinal Heenan House DS0000005890.V331866.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 &18. Quality in this outcome area is excellent. The home has a satisfactory complaints system with evidence that residents feel their views are listened to and acted upon. The staff’s training in the Protection of Vulnerable Adults protects residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information is clearly provided for residents in the event of them, or their relatives wanting to make a complaint about the home or its staff. There is a robust policy and procedure in place for responding to an allegation or suspicion of abuse, with training provided for staff in the protection of vulnerable adults. The training includes ‘how to identify signs and symptoms of abuse’ and ‘what to do if there is a suspicion / or alleged abuse’. Since the previous inspection, there have been no complaints received by the Commission for Social Care Inspection. All comment cards received from residents confirmed they knew who to speak to if they were not happy. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23, 24 & 26. Quality in this outcome area is good. The residents are provided with a clean and comfortable environment, where bedrooms are well personalised. This means that residents will feel at home with their belongings around them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Case tracking showed that on an individual basis, aids and adaptations are in place to meet residents’ needs. A range of other aids and adaptations were seen in communal areas, such as grab rails, raised toilet seats, hoists and specialist baths for assisted bathing. There is a passenger lift which accommodates a wheelchair, giving those with mobility problems equal access to all parts of the home. Doorways to communal areas and bathrooms are wide enough to enable wheelchairs to pass through and wheelchair storage is available. The corridors are wide and have handrails fitted. A loop system is Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 16 in place in rooms and the chapel so that those with hearing problems are not disadvantaged. All rooms used by residents have emergency call bells. The home’s pre inspection questionnaire evidenced that checks made on all equipment are kept up to date. The manager ensures all equipment and areas inside and outside the home, are well maintained. All the radiators throughout the home are fitted with touch cool surfaces, to protect residents from the risk of injury. Fail-safe devices are fitted to all hot water outlets used by residents to ensure water is delivered close to 43ºC. Regular checks of water temperatures are made and recorded to maintain safety, a comprehensive record of all work undertaken throughout the home is kept. The premises were found to be clean and free from offensive odours and visitors commented that the home had a good standard of cleanliness. Both from comment cards received and by speaking to residents, it was clear that all are pleased with their accommodation, especially bedrooms. All bedrooms were well personalised with resident’s own furniture and memorabilia. There is a quality monitoring system for the home, this means that the home is keen to ensure that residents is run in their best interests. Comments included “Good environment, friendly and attentive staff”, “makes the residents feel at home”. . However, some of the communal areas, bedrooms and the outside of the home now need refurbishing and redecoration, this would add to the overall appearance of the home. The manager is aware of this and is to report to the governing body of the home. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. The numbers of staff on duty were satisfactory to meet the needs of the people living at the home. The policies and procedures for the recruitment of staff provide safeguards for the protection of residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas were included in the pre inspection information where a consistency of staff members was noted. Many of the staff have been at the home for a long time, there is very little turnover so both staff and residents get to know each other well. All residents spoke highly of the staff, comments included “staff are very nice”, “all staff are very good”, and “very happy living here, staff are very friendly”. A relative added “must express my gratitude to all the staff at Cardinal Heenan for their outstanding care and attention and devotion to my Father’s well being and quality of life”. Residents said their call bells were answered promptly during the night and that staff were always pleasant to them. When asked the question “Do staff listen and act on what you say?” the response was “in every way”. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 18 Staff files contain information to ensure that persons employed are fit to work at the home and competent to do their jobs. Prospective staff need two written references including one from their previous employer and need to show their reasons for applying for a “caring” role with residents. However the home was advised that all employees should provide their work histories, including any gaps in employment, to further safeguard residents, the manager said this would be completed by each staff member. Training is set up and National Vocational Training (NVQ) is ongoing, at present 86 of the 22 care staff, have achieved level 2 or above, this is above the recommended ratio by the Care Homes Regulations 2000. 25 staff hold first aid certificates. 8 staff are trained to administer medication. All training certification is held on staff files, further training needs and interests are noted and planned for. Criminal Records Bureau (CRB) clearances are on file for all employees, any new staff will need clearances before starting work at the home. Staff receive mandatory training in moving and handling, fire safety, first aid, food hygiene, and the administration of medication. There was documented evidence that staff had also received other appropriate training in abuse awareness, mental health awareness, dementia and Alzheimer’s awareness. Staffs are positively encouraged to attend training courses, with overtime payment for attendance during off duty hours. A good relationship was noted between staff and residents and there was a relaxed atmosphere throughout the home. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is excellent. The home reviews aspects of its performance through consultation, which includes seeking the views of residents, thereby ensuring the home is run in their best interests. Good procedures are in place to safeguard the financial interest of residents and the management ensures up to date maintenance in the home, this is to protect the health, safety and welfare of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home continues to be well managed and run on a daily basis by Stewart Hilton who is well qualified and has good experience and knowledge of many of the problems that older people develop. Residents and staff respect and like him and find him approachable and friendly. Relatives spoke well of the Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 20 manager, they felt the home was “performing to a high standard” with “competent management”. The Responsible Individual for the home completes monthly reports addressing the well being of the residents and relating to the National Minimum Standards, Care Homes Regulations 2000. Resident’ views are sought through their meetings which are held on a regular basis. The minutes from the last meeting showed a good attendance and included suggestions to future outings. Comments about the staff and general running of the home were very good and residents were in general happy with the way their home is run. Records showed that an inventory of personal goods and furniture brought into the home, is completed for each resident and that any financial transaction undertaken on behalf of their behalf is recorded, although the home does not act as appointee for anyone. Residents are encouraged to handle their own finances or elect family or a solicitor to do this for them. Cardinal Heenan House has comprehensive Health & Safety Policies, knowledge of these forms part of staff induction. As stated previously, staff undertake mandatory training in Moving & Handling, Fire, Control of Hazardous Substances, First Aid, Infection Control and Food Hygiene. Fire drills are carried out, maintenance of equipment is completed and relevant certificates are held. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 21 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 4 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 Timescale for action 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. Refer to Standard OP29 OP19 Good Practice Recommendations Gaps in employment records should be explored to ensure that new staff are suitable for the job they apply for. A programme of renewal of the fabric and decoration of the premises should be produced and implemented with records kept, to ensure the home’s environment keeps to a good standard. Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cardinal Heenan House DS0000005890.V331866.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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