Inspection on 25/07/06 for Heslam Homes Limited

This inspection was carried out on 25th July 2006.

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

Heslam Homes Limited 19/08/08

Heslam Homes Limited 29/08/07

Heslam Homes Limited 04/01/06

Heslam Homes Limited 09/08/05

Heslam Homes Limited 18/10/04

Heslam Homes Limited 19/05/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heslam Homes Limited Heslam House 3 St Francis Road Blackburn Lancs BB2 2TZ Lead Inspector Jane Craig Key Unannounced Inspection 09:30 25 and 28th July 2006 th 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 Heslam Homes Limited DS0000005825.V297264.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. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heslam Homes Limited Address Heslam House 3 St Francis Road Blackburn Lancs BB2 2TZ 01254 201513 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) Mrs Carina Lamb Mr Philip Richard Lamb Miss Linda McCallion Miss Sharon Louise Park Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The registered provider should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection The service shall at all times ensure that the minimum staffing levels in the home comply with the formula detailed below. The service must also ensure that as and when service users dependency levels increase the staffing levels are closely monitored and if necessary adjusted in response to any change. Up to and including 15 Service Users 08:00hrs - 22:00 hrs Management - 1 person on duty at all times Care Staff - 1 person on duty at all times 22:00hrs - 08:00 hrs 1 person on waking watch whose duties may include a small percentage of domestic work. 1 person on call in the vicinity (on the Campus or within approximately 3 minutes travelling distance) Ancillary Staff: Domestic - 25 hours per week Cook - 35 hours per week Up to and including 16-19 Service Users 08:00hrs - 18:00 hrs Management - 1 person on duty at all times Care Staff - 2 persons on duty at all times 18:00hrs - 22:00hrs Management - 1 person on duty at all times Care staff - 1 person on duty at all times A member of the management team to be on call at all times and clearly identified on the staff roster. 22:00hrs - 08:00hrs Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 5 2 persons on waking watch whose duties may include a small percentage of domestic work. One of the above to be designated as a senior person. Ancillary Staff: Domestic - 25 hours per week Cook - 35 hours per week Up to and including 20-24 Service Users 08:00hrs - 13:00hrs Management - 1 person on duty at all times Care Staff - 3 persons on duty at all times 13:00hrs - 18:00 hrs Management - 1 person on duty at all times Care Staff - 2 persons on duty at all times 18:00hrs - 22:00hrs Management - 1 person on duty at all times Care Staff - 1 person on duty at all times A member of the management team to be on call at all times and clearly identified on the staff roster. 22:00hrs - 8:00hrs 2 persons on waking watch whose duties may include a small percentage of domestic work. One of the above to be designated as a senior person. Ancillary Staff: Domestic - 35 hours per week Cook - 35 hours per week Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 6 Date of last inspection 4th January 2006 Brief Description of the Service: Heslam House is registered to provide personal care to a maximum of 24 older adults. The home is a large detached property set in its own established and well-maintained grounds. There is a large enclosed garden and patio area with seating for residents. Parking space is provided at the front and side of the building. Heslam House is located in a residential area of Blackburn, within easy reach of shops and other local amenities. The home has three lounges and one dining room. Bedroom accommodation is provided on two floors, the upper floor is accessed by a stair lift. All rooms are currently used for single occupancy. Prospective residents are given information about the home during a preadmission visit. They are given a copy of the service user’s guide on admission and a copy of the latest Commission for Social Care Inspection report is displayed on the resident’s notice board. At 25th July 2006 the weekly fees for all residents were £354. The cost of newspapers, hairdressing, toiletries and transport for trips out were not included in the fees. Residents were also charged extra for transport and escorts for hospital appointments. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 7 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place over one day. The report also includes information submitted by the registered people. None of the twenty comment cards sent out to the home for residents and visitors were returned. At the time of the key inspection visit there were 16 residents accommodated. The inspector met with residents and visitors and spent time observing interactions between staff and residents. Wherever possible residents were asked about their views and experiences of living in the home and some of their comments are quoted in this report. Discussions were held with the registered manager and three members of staff. The inspector made a tour of the premises and looked at a number of bedrooms. Records and documents were viewed. What the service does well: All of the residents spoken with said they were happy with the home and visitors said that their relatives were settled. One resident said, “there is nothing I would change.” A number of residents expressed their satisfaction with the staff. One resident said, “the girls come and help me with anything I need,” another said, “they are all very kind.” When asked what she thought the service did well, one resident said, “The best thing about the home is the staff.” Residents said that staff respected their privacy and dignity. One resident said that when staff were helping with personal care they never made her feel uncomfortable. Another said “they always knock on my door, they don’t just walk in.” Visitors said they were made welcome and residents were happy with the way their relatives were treated. One said, “the staff are lovely with my grandchildren when they come to visit.” Residents were satisfied with the daily routines in the home. One said she had breakfast in bed every morning. Staff made sure residents had choices wherever possible. One resident said, “If I don’t fancy what’s on the menu they are very good and ask me what I want.” Residents were very complimentary about the meals. Residents were given clear information about how to make a complaint. They said they would be able to talk to the manager if anything was not right. Staff understood about the need to protect vulnerable adults from abuse. They had all received training and understood how to report any allegations, which helped to safeguard residents. The way new staff were recruited provided safeguards for residents. The manager made sure that all new staff had full background checks before they started work at the home. There was a low turnover of staff which meant that residents became familiar and comfortable Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 8 with the staff team. A visitor to the home said, “some have been here a long time 20 years some of them – that says a lot doesn’t it?” Residents also benefit from an experienced and qualified manager, who they said they could talk to. Residents had opportunities to give their opinions about the service. They could attend meetings every few months and they were invited to fill in a questionnaire at least once a year. What has improved since the last inspection? What they could do better: Residents said that staff looked after their health and made sure that the doctor was called whenever anyone was poorly. However, there were no assessments or plans to show how risks to residents’ health, for example from falls, could be minimised. There had been some improvements in the way staff looked after residents’ medicines but further improvements were needed to make sure that medicines were managed safely. Some areas of the home were in need of redecoration and some items of furnishing needed replacing. A number of radiators had been covered since the last inspection but the programme for covering the others had not been followed. Unguarded radiators could cause severe injury to residents should they fall against them. The owner and manager must address this. Although half of the staff held a nationally recognised qualification in care, other opportunities for training were limited. None of the staff were fully up to date with health and safety training which could result in residents and themselves being put at risk. The lack of health and training was identified during the last inspection but the registered person had not addressed it within the agreed timescale. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 9 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. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 10 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 Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process was thorough and ensured that residents had sufficient information to help them to make a decision about moving in and staff had enough information to understand the resident’s care needs. EVIDENCE: Residents had access to information about the home. One resident said the service user’s guide was “good to read as it tells you everything.” All residents were given a copy of the terms and conditions of residency. Senior staff assessed all prospective residents before they were offered a place at the home. The quality of the assessments had improved since the last inspection. They provided staff with detailed information about the resident’s care needs. Letters were sent out to residents to confirm that their needs could be met at the home. These were under review and the proposed format would be an improvement. The home did not provide intermediate care. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although improving, the shortfalls in planning and delivering care may result in residents’ needs not being completely met. EVIDENCE: The care records for three residents were inspected and others were viewed in less detail. All residents had an assessment or profile to identify their needs but they were not always addressed, for example, one resident with a diagnosis of depression did not have a care plan for this. The format for care plans had improved. The plans for personal care included individual details about the type and level of care the resident preferred, and provided staff with excellent directions. Staff received training about care values and two talked about how they preserved residents’ privacy and dignity. A resident said that staff always waited outside the bathroom door and another said that staff didn’t make her feel uncomfortable when they were helping with personal care. Throughout the inspection staff were seen to speak with respect to residents. Residents’ health care needs were not assessed. One resident was using pressure relieving equipment but there was no risk assessment or plan to Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 13 support this. Two residents were admitted with a history of falls but there were no risk assessments in place. Another resident had sustained a number of falls in a short period of time, there was no assessment to identify the cause or strategy to minimise the risk. Several residents needed assistance with mobility but there were no moving and handling assessments. Despite the lack of assessments and plans, staff did sometimes identify and address health care risks. One resident had been referred to the district nurses after falling out of bed twice and one resident had been referred to the dietician because of weight loss. Residents said their healthcare needs were met. One said that staff had called in the doctor when she “hadn’t been so good.” Another said, “if there is anything bothering you they sort it out.” A relative said that staff had called out the GP about a health care issue that had been identified during the pre-admission assessment. The medication policy had been updated but there were still some omissions. Records of medicines entering and leaving the home were in place. There had been some improvements in Medication Administration Record (MAR) charts. Handwritten entries corresponded exactly with medicine container labels and the entries were signed and witnessed. There were no gaps on MAR charts. Codes used to indicate that residents had not taken medication were incorrect, which meant that staff did not know the reason why medicine had not been given. The criteria for the administration of ‘when required’ medication was not clearly defined and recorded, which could lead to the risk of over- or under-medication. Four staff had completed medication training and the manager had provided in-house training for five staff who were waiting to attend the course. Medicines were stored securely and there was restricted access to keys. Temperatures of storage facilities were monitored and generally controlled at an acceptable level. There was excess stock of some medicines which created a risk of residents being given out of date medicines. There were a number of dressings belonging to residents no longer at the home or with the name labels removed, which may indicate that prescribed items were shared. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had choice and control over their daily lives. Routines, activities and meals suited residents. EVIDENCE: Information about residents’ preferred daily routines, interests, food likes and dislikes were recorded on their profiles. The profiles also identified any religious or cultural needs. A visitor said that the manager had asked her mother about all of this when she came to do the pre-admission assessment. Residents were satisfied with the routines in the home. They said they were able to get up and go to bed when they wanted. One said she was an early riser and staff brought her a cup of tea in bed then came for her at 7.30. This corresponded with her usual routine at home. Another said that she always had her breakfast in bed. Staff were seen to offer residents choices about what to eat and drink, where to sit and what to do. Two of the residents’ spoken with said they preferred to spend the day in the their bedrooms. There had been some improvement in the level of social and recreational activities. There was a dedicated member of staff to organise activities on two afternoons per week and there had been a few large events at the home. Most of the residents spoken with said the amount of activities was sufficient. One said, “they don’t force you to do anything,” another said it was “just fine for Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 15 me.” Suggestions for activities were on the agenda at every residents’ meeting. There was a shortage of suitable activities for a number of residents who were partially sighted or registered blind. One said, “they have dominoes, skittles and bingo but I can’t even watch.” There were no restrictions on visiting unless at the request of residents. Visitors said they were made welcome and offered a cup of tea or a meal. One resident said, “the staff are lovely with my grandchildren when they come to visit.” Visitors to the home included representatives from the local churches and Salvation Army. All residents spoken with were happy with the meals. Their comments included, “lovely, you can have as much or as little as you want,” “very good food; nicely cooked,” and “food’s alright, now’t to grumble about.” Records showed that residents wee offered a nutritious and varied diet with some element of choice. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The procedures for safeguarding residents were understood by staff. Residents were confident that complaints would be dealt with appropriately. EVIDENCE: There was a clear and concise complaints procedure displayed on the notice board. None of the residents spoken with had any complaints. They said they would speak to the manager if they did. One resident said she had gone to the manager with a complaint some time ago and this had been dealt with. Records of residents’ meetings showed that they were always asked if they had any complaints or concerns. Staff were aware of when they should try to resolve complaints and when to pass them upwards. There had been no complaints over the past year. All staff had training in the protection of vulnerable adults. There was written guidance available in the home, which included reporting procedures. Staff were aware of their responsibilities in reporting any allegations to the manager or to outside agencies if necessary. The registered manager was knowledgeable about how to deal with any suspected or reported abuse. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and comfortable but wear and tear of decoration and furnishings in some areas detracted from residents’ comfort. The lack of covers on all high risk radiators place residents at risk of injury. EVIDENCE: A tour of the premises evidenced that the home was in a good state of repair. Some of the bedrooms were highly personalised. There were some bedrooms identified as needing redecoration and, as highlighted during the last inspection, several bedside cabinets were scratched and unsightly. Several carpets were rucked, and whilst they did not present a tripping hazard, they did not look good. Other carpets needed replacing. The dining room needed redecorating. The registered provider had highlighted some of these issues during her unannounced visits to the home and the annual development plan included some areas for renewal and redecoration. Residents were satisfied with the environment, which was generally comfortable and homely. One resident said the main lounge was a “lovely light Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 18 room,” and another said, “my bedroom’s very nice, my own little haven.” Residents had been involved in planned improvements to the garden. Some radiator covers had been fitted where the risk of injury to service users was assessed as high. According to the manager’s assessments a number of other guards should have been fitted to high risk areas by June 2006 but this had not been done. The home was clean, tidy and fresh smelling. One relative said that the lack of offensive odours was very important to them and one of the reasons why they had chosen the home. Staff had received training in infection control procedures and had responded appropriately to a recent outbreak of infection. Liquid soap was available in the communal hand washing areas of the home but there were no disposable towels. Residents said they were satisfied with the laundry service. One resident said that clothing sometimes went missing but usually turned up. The laundry was adequately equipped for the size of the home and on the day of the visit it was tidy and organised. Heslam Homes Limited DS0000005825.V297264.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff to meet the needs of the residents, who benefited from a stable and experienced staff team. Although half the staff held an NVQ, the lack of staff training in other areas may result in staff not being made aware of current good practice. EVIDENCE: Examination of the duty rosters showed that staffing levels met or exceeded those specified on the registration certificate. Staff and residents said there were always enough staff on duty to meet the residents’ needs. Two of the residents and a member of staff said that staff usually had some time to sit and have a chat with residents and they were observed doing so on the day of the inspection. Residents were very complimentary about the staff team. One resident said, “they are a good bunch,” another said, “I can’t think of one fault, they go out of their way to be helpful.” A visitor commented, “some have been here a long time 20 years some of them – that says a lot doesn’t it?” There was a very low turnover of staff and no agency usage. Staff were recruited as per the homes procedures. The files of 2 recently recruited staff contained all the required information and documents. The manager had introduced a new induction training programme that met the 12 week, common induction standards. Staff said they met every week with Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 20 the manager to discuss their progress and have competencies assessed. Induction training in health and safety was still not being carried out within the recommended timescale. One member of staff had been at the home for over three months and had not completed the health and safety awareness standard. 50 of care staff were trained to NVQ level 2 or above but other opportunities for training were limited. Heslam Homes Limited DS0000005825.V297264.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well organised and managed in the best interests of residents. However, residents and staff may be put at risk because of lack of attention to health and safety issues. EVIDENCE: One of the registered managers was qualified to NVQ level 4 in care and held the Registered Manager’s Award. The other manager, who took on the role of deputy, was qualified to NVQ level 3. Both managers took short courses to update their knowledge and skills and had recently attended medication training and a course on diabetes. At the time of the inspection the manager showed herself to be knowledgeable about her role and responsibilities. Staff and residents said the home was well organised and managed. Staff said they felt supported by the manager. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 22 There were systems in place to monitor the quality of the service. Residents had opportunities to make their views and opinions known. Meetings were held every 2 months and residents said they were able to “make and different suggestions.” The manager said that any issues brought up which involved staff would be put onto the staff meeting agenda. Residents and visitors were asked to complete surveys. Four residents returned theirs this year. Comments were all positive and the one suggestion had been actioned by the manager. Residents were also invited to complete a survey about the admission process. There were external quality monitoring systems, for example, the home had just been re-assessed for the Blackburn with Darwen quality assurance award and was waiting for the results. Residents’ families managed their finances although some residents handled their own personal allowances. Accurate records were kept of any monies handed over to staff for safekeeping. Following a requirement at the last inspection, accidents and incidents were recorded on the appropriate forms and reported where necessary. However, the manager did not audit the reports and investigate any multiple falls or accident patterns. Many of the policies and procedures for the home had not been reviewed since 2002, despite a recommendation at the last inspection. None of the staff had received update training in moving and handling. Only two staff had a current first aid qualification and basic food hygiene training was not up to date. The manager conducted fire drills every two weeks and fire prevention information was incorporated into the drills. Fire alarms and emergency lighting were tested every week. Servicing of the fire system and equipment was up to date but there was no fire risk assessment. Not all portable electrical appliances had been tested but maintenance and servicing of other installations and equipment was up to date. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 23 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 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 3 17 X 18 3 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 1. OP7 15 The registered person must 31/10/06 ensure that all resident have a plan of care, which sets out their personal, health and social care needs and how they are to be met. (Timescale of 20/12/04 not met) 2. OP8 13 Care plans must include risk 31/10/06 assessments and plans, with particular attention to falls, moving and handling and pressure sore risk. (Timescale of 20/12/04 not met) 3. OP9 13(2) There must be a complete set of 30/09/06 policies for the management of medicines (Timescale of 31/03/06 not met) 4. OP9 13(2) Correct codes must be used on 31/07/06 MAR charts to explain why the resident has not taken the prescribed medication. 5. OP9 13(2) Any medication or dressings no 31/07/06 longer in use must be returned to pharmacy. 5. OP25 13 The programme to fit radiator 31/10/06 guards to high risk areas must continue to timescales set by the registered person. 6. OP30 18 New staff must receive 30/09/06 awareness training in safe working practices during the first few weeks of employment. (Timescale of 30/09/05 not met) Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 25 7. 8. OP38 OP38 23(4) 18 9. OP38 13(4) The registered person must carry 31/08/06 out a fire risk assessment. Staff must receive update 30/11/06 training in safe working practice topics. (Timescale of 30/04/06 not met) The registered person must 31/08/06 ensure that all portable appliances are safety tested. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations Standard OP9 1. There should be no excess stocks of medication. 2. OP9 Criteria for the administration of when required and variable dose medication should be clearly defined and recorded. 3. OP9 Handwritten amendments to MAR charts should be signed and witnessed. 4. OP12 The registered person should further develop the programme of activities to meet the social and recreational needs of all the residents. 5. OP19 All rooms and furnishings in need of redecoration or renewal should be identified and included in the development plan. 6. OP30 The registered person should review the training needs of all staff and develop an annual training plan. 7. OP37 Policies and procedures should be reviewed annually. 8. OP37 Accident records should be audited. Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heslam Homes Limited DS0000005825.V297264.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!