Inspection on 29/08/07 for Heslam Homes Limited

This inspection was carried out on 29th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Heslam Homes Limited 19/08/08

Heslam Homes Limited 25/07/06

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 Unannounced Inspection 29th August 2007 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 Heslam Homes Limited DS0000005825.V342539.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.V342539.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.V342539.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 Managerment - 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.V342539.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.V342539.R01.S.doc Version 5.2 Page 6 Date of last inspection 25th July 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 wellmaintained 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. People thinking about using the service are given information about the home during a pre-admission 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 29th August 2007 the weekly fees for all residents were £368. The cost of newspapers, hairdressing and toiletries were not included in the fees. People were also charged extra for transport and escorts for routine hospital appointments. Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 7 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Heslam House on the 29th August 2007. At the time of the visit there were 17 people living at the home. The inspector met with a number of them and asked about their views and experiences of living at Heslam House. Some of their comments are included in this report. Two people living at the home were case tracked. This meant that the inspector looked at their care plans and other records and talked to staff about their care needs. Seven people living at the home and eight family carers had returned surveys before the inspection visit. Two healthcare professionals also completed questionnaires. Most of the views about various aspects of the home were positive. During the visit discussions were held with the one of the registered managers, three other members of staff and five visitors. The inspector looked round the home and viewed a number of documents and records. This report also includes information taken from the Annual Quality Assurance Assessment (AQAA), which is a self-assessment that the owner or manager has to fill in and send to the Commission every year. What the service does well: The manager visited people who were thinking of moving into the home to assess what care they needed and to make sure that their needs could be properly met at Heslam House. People who returned surveys indicated that they were given enough information about the home to help them to make a choice. People using the service said that staff respected their privacy. Family carers also said that staff were polite and respectful. One said, “The staff are absolutely lovely with mum and always very polite.” A healthcare professional wrote that the staff “care for elderly people with respect and concern.” The complaints procedure was displayed. People who returned surveys said they knew who to speak to if they were unhappy about anything. Most family carers indicated that staff usually responded appropriately if they raised any concerns. People were able to bring in items to personalise their rooms. People spoken with were satisfied with their bedrooms. One said, “I am very happy with the Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 8 room,” and another said, “I have a nice room and a comfy bed.” The home was clean and there were no unpleasant odours. People who returned surveys indicated that it was always like that. Most of the staff team, including the managers, had been at the home for a number of years. This meant that people living there received consistent care from staff who knew them. One visitor said, “The manager and a lot of the staff have been here a long time so that always speaks volumes.” Most of the people spoken with made complimentary remarks about the staff. One person described them as “Friendly, obliging and cheerful, all perfect.” 80 of the care staff held a nationally recognised qualification in care called an NVQ. This meant that they had the knowledge and skills necessary to meet the needs of the people living at the home What has improved since the last inspection? What they could do better: There had been some improvements in the way medicines were managed. However, some areas needed further improvement to make sure that people received their medicines as they should. The staff carried out assessments to check whether people had risks to their health, for example, risks of falls. They should then draw up strategies to try to control the risk and protect people’s health and safety. The managers and staff must make sure that they use the right equipment to move people who are not able to move independently. Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 9 The manager must make sure that all staff receive enough training and practice so that they know exactly what to do in the event of a fire. The manager should make sure that any recommendations from other agencies, such as environmental health, are carried out. This is to protect the health and safety of people living and working at the home. 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. Heslam Homes Limited DS0000005825.V342539.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.V342539.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3and 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 enough to ensure that people were only admitted if their needs could be met. EVIDENCE: People who returned surveys and those spoken to during the visit said they received written information about the home before they moved in. One family carer said that the service user’s guide told them everything they needed to know. People who were asked said they had a contract. People were generally assessed by health or social care professionals before they were referred to the home. The manager or other senior staff also carried out an assessment with anyone thinking of coming into the home. This helped to make sure that the staff and facilities at Heslam House could meet the person’s individual needs. Standard 6 is not applicable because intermediate care is not provided at the home. Heslam Homes Limited DS0000005825.V342539.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. 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. Shortfalls in care planning and delivery meant that not everyone’s health and personal care needs were met. EVIDENCE: Two care plans were inspected as part of the case tracking process and others were viewed in less detail. When a new person was admitted a 72-hour care plan was drawn up. This ensured that immediate needs were met whilst giving the person time to settle in. It also gave staff time to continue to assess and form a clear picture of the person’s longer term needs. Each person had a profile, which contained detailed information about his or her individual personal care needs and preferences. Care plans were personalised and provided staff with good, detailed directions about the person’s individual’s needs and the care to be provided. The plans took into account people’s wishes for independence. Plans were evaluated monthly and updated when there were any changes. People signed agreement to their Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 13 plans and the manager said that wherever possible reviews were carried out with the person or their family to make sure that they could make suggestions if they wanted. As required following a previous inspection, care plans included health care risk assessments for moving and handling, falls, and risk of developing pressure sores. The assessments were kept under review and were updated. However, there were no preventative strategies to try to minimise risk. Care plans were only written when people had had a number of falls or when they had developed a pressure sore. The manager had already identified this shortfall and discussions took place as to how it could be rectified. Several people had moving and handling needs. There was no hoist and staff confirmed that they were manually lifting one person, which increased the risk of injury to both the person and the staff. Staff said that other people may benefit from handling equipment because of their fluctuating abilities, but their assessments did not make this clear. There was evidence that people were referred to healthcare professionals. Advice was not always incorporated into the care plans, which meant that staff had to rely on verbal messages, which increases the risk of mistakes and inconsistency. For example, one person did not receive updated care and treatment until four days after it was prescribed. The manager stated that this was not usual and the healthcare professionals who returned surveys indicated that staff always acted on advice they gave. People using the service indicated on their surveys that they usually received the care and medical support they needed and more than one person on the day of the visit said they were well looked after. One person said, “Staff understand me and give the care I need.” Most family carers indicated that the service usually met the needs of their relatives and gave the support that they expected. One person said, “We are really glad she so well looked after.” There had been improvements in the way medicines were handled and all the requirements made following the last inspection had been met but there were still some shortfalls. Policies for managing medication had been reviewed. Staff who were responsible for handling medication had received training and they also had written guidance to refer to. There were complete records of medicines entering and leaving the home. There were no gaps on Medicine Administration Records (MAR) charts and appropriate codes were used to indicate why medicine had been omitted. Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 14 There were some handwritten entries on MAR charts that were not signed or witnessed which increased the risk of errors. Most medication was supplied in monitored dose packs. Medicines that were not had the dates of opening recorded on their packaging to assist with audit. A sample audit showed that most people had received the right amount of medication as it was prescribed. However, there was one discrepancy, which could indicate that staff were signing for medicines they had not administered. Variable doses were not recorded which meant that those medicines could not be audited and staff could not evaluate which was the most effective dose. A number of people were prescribed “when required” medicines but there was no written criteria to alert staff when they should be given to people who were not able to request it. This could result in people being under or over medicated. Storage of medication was safe. Daily temperatures were recorded and maintained within acceptable limits. There were no excess stocks of medicines. Most staff had received training that covered core care values. They discussed how they upheld people’s rights to privacy when they assisted with personal care and gave examples as to how they ensured people were treated with dignity. One member of staff said, “we respect people’s wishes to do or not to do something, we don’t try to overrule them.” People using the service said that staff respected their rights. One person said, “I like to do things for myself if I can and staff know that.” Another said, “I always have the same person to help with bathing which makes it much less embarrassing.” Family carers also said that staff were polite and respectful. Heslam Homes Limited DS0000005825.V342539.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): 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. Daily routines and meals suited the majority of people living at the home. Improvements in the level of activities meant that more people were being assisted to meet their social and recreational needs. EVIDENCE: Information submitted in the Annual Quality Assurance Assessment (AQAA) indicated that the level of organised activities had improved and the aim was to create even more opportunities for people to be engaged in activity. Records showed that group activities were offered on a more regular basis. Some people who were asked said this was enough and they chose what they wanted to join. One person said, “I do the exercises every fortnight that’s all I want,” and another said, “I play dominoes now and again and that’s enough.” Others who were unable or did not want to join groups said they enjoyed talking to the staff when they had time. One person mentioned at a residents’ meeting that they would like staff to be able to chat more. The manager said this did happen and two members of staff talked about making time to sit with people in the lounges. A family carer also remarked that she thought it was nice that she saw staff sitting with residents talking and laughing together. Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 16 Profiles contained information about people’s likes, dislikes and routines. For example, times they liked to get up and go to bed. One of the surveys indicated that people might be assisted to get up too early. There was no evidence from talking to staff and people living at the home that this was the case but the manager said she would monitor this. Staff said that people living at the home could make choices about all aspects of their daily lives. People confirmed that they were able to choose their meals, where they spent their time and what they did during the day. Staff used information recorded on personal profiles to assist people who were not able to easily say what they liked. There was an open visiting policy. Visitors said they felt welcome in the home. One said, “I find it wonderful here. They are very welcoming and always offer me a drink or a meal if it is near mealtimes.” Some people went out with family and the programme of activities included walks and trips out. There was a religious service held in the home every month and some people went out to church with their families. Most people who returned surveys or were asked indicated that they liked the meals. One person said, “The food is very good, a good variety and always nicely cooked.” The menu had been drawn up using information from discussions at residents’ meetings. There was a choice at every meal and the manager that alternatives to the menu were readily available. One person said, “Meals are good, they give me something else if I don’t like it.” Records of meals showed that people were offered a balanced diet. Heslam Homes Limited DS0000005825.V342539.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service were safeguarded by the complaints and protection procedures followed by staff. EVIDENCE: There was a clear complaints procedure on display in the hall. People who returned surveys indicated that they knew who to speak to if they were unhappy and most people indicated that they knew how to make a complaint. Family carers spoken to at the time of the visit said they had no complaints and those who completed surveys indicated that staff usually responded appropriately when they raised any concerns. There had been no complaints directly to the service. Some concerns about staffing levels and routines in the home were raised on the surveys sent out to people using the service and family carers. These were discussed with the manager at the time of the visit. Complaints records showed that the managers had responded appropriately when concerns had been raised in a similar way during a previous inspection. New staff received training in safeguarding vulnerable adults during their induction training. Records showed that other staff had refresher training and there was written guidance available for reference. Staff spoken with during the visit were aware of their responsibility to report any allegation to the Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 18 manager. They were also aware of how to report outside the home if necessary. Policies were in place to protect people living and working in the home from racial discrimination and to ensure equal opportunities for all. Heslam Homes Limited DS0000005825.V342539.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): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the environment helped to make the home comfortable but lack of attention to infection control practices may put people living and working at the home at risk. EVIDENCE: As required following the last inspection all the radiators assessed as high risk had been covered. However, the assessment had not been reviewed for over a year which meant that those originally deemed as low risk may pose a higher risk to new people in the home. From walking around the home it was evident that repairs were carried out. There had been some redecoration and renewal of carpets in various areas throughout the home. However, the holes in the dining room walls had still not been repaired and looked unsightly. Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 20 Several people commented that they were happy with their rooms, many of which were highly personalised. One person said, “it’s a small room but suitable; I can fit everything in.” Another person who had a double room said, “I’m thankful that I’ve got a nice big room for all my things.” The home was clean and free from unpleasant odours. People who returned surveys indicated that it was always like that. There were policies and written guidance on controlling the spread of infection but not all staff had received training. The manager said it was planned over the next few months. The deep cleaning recommended from the last environmental health inspection had not been done. There was no planned date for the work to be carried out. The service did not have a separate contract for the removal of offensive / hygiene waste as defined in recent Department of Health guidance. The manager agreed to check with the current waste disposal company as to whether this was needed. The laundry was adequately equipped for the size of the home and on the day of the visit it was tidy and organised. There were no complaints about the laundry and one person said, “The laundry is not bad, I get everything back that I send.” Heslam Homes Limited DS0000005825.V342539.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): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home were protected by the recruitment practices and were supported by a stable and experienced staff team but the staffing levels may not meet the needs of people at all times. EVIDENCE: Staffing levels met the minimum numbers stated on the conditions of registration. However, a concern had been raised through the surveys that the evening staffing levels were not sufficient. On the day of the inspection most people thought there were enough staff. One person said, “There are enough staff as a rule, if I press the button they come up.” Another said “There’s always someone there, I’ve only to pull that.” (staff call bell). Staff said sometimes people had to wait for assistance during the busy time in the evening and that sometimes people in the lounges were unsupervised. A relative who visited the home in the evenings agreed that they sometimes had to wait for staff to answer the door but said, “I would rather I had to wait than one of the residents.” The manager was made aware of the concern and said staffing levels would be monitored. Several people spoken with at the time of the visit made very favourable comments about the staff. One person said they were, “Friendly, obliging and cheerful, all perfect,” and another said, “staff are great. All of them treat me well.” A visitor to the home said, “the staff make it good.” Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 22 There was a very low turnover of staff and no agency usage. A family carer commented that the manager and a lot of the staff had been at the home for a number of years which she saw as very positive. The files of two new staff were inspected. Even though both had worked at Heslam House before, the manager ensured that new pre-employment checks were carried out. Both had the required information and documents on file. The induction training programme for new staff met the Skills for Care common induction standards. One of the new staff was working through the programme and had completed awareness training in most of the safe working practice topics. There was an assessment of competency after each module which was signed off by the manager. There had been improvements in training for other staff but training in the safe working practice topics was not quite up to date. There was some training planned for October. Information included in the AQAA indicated that 80 of care staff held an NVQ level 2 or above. Heslam Homes Limited DS0000005825.V342539.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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was run in the best interests of the people living there but minor shortfalls in health and safety practices could place people at risk of harm. 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. The site visit was conducted with the help of the deputy manager who was knowledgeable about her role and responsibilities. A family carer wrote that the home was well organised and managed. The service held the Blackburn with Darwen Quality Assurance Scheme award. People using the service had an opportunity to express their views of the home on the annual quality survey but there had been a poor response this year. Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 24 People living at the home were also able to put suggestions forward during the residents’ meetings held every two months. Minutes showed that the meetings were well attended. Visitors were also invited to complete questionnaires and make suggestions for improvements. Those seen were all very positive and the only suggestion was for more activities which was already being actioned. The managers did not act as agent or appointee for anyone living at the home. Family carers managed finances for most people. Records were kept of any money or valuables handed over for safekeeping and receipts were kept when any money was paid out on someone’s behalf. The records were audited every few months which may not be sufficient if staff ever needed to trace back an error. The manager conducted regular fire drills which included an element of fire prevention training. Staff who were asked were aware of the fire procedure and what their role would be in the event of a fire. However, there were four staff, some of whom worked on night duty, who had not been involved in a drill, or had fire safety training for over a year. This could potentially put people living and working at the home at risk. Fire safety equipment and systems were serviced and tested regularly. Servicing of gas and electrical systems and appliances was also up to date which ensured that the home was safely maintained. Accidents were recorded and although there were no formal audits, it was evident that the information was used when evaluating care. Heslam Homes Limited DS0000005825.V342539.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 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP8 Regulation 13(5) Requirement To protect the health and safety of the person and of staff, anyone with moving and handling needs must be assessed and the appropriate equipment and aids must be used to transfer them. Medicines must be given as instructed on the prescription to promote the health of the person living at the home. In order to protect the health and safety of people living and working at the home all staff must receive training in fire prevention and participate in regular fire drills. Timescale for action 30/09/07 2. OP9 13(2) 15/09/07 3. OP38 23(4)(de) 30/09/07 Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 27 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 OP7 OP7 Good Practice Recommendations Care plans should include strategies to minimise risks to people’s health and safety, for example, from falls. Advice from health care professionals should be recorded on care plans in order to ensure that the advice is carried out. Criteria for the administration of when required and variable dose medication should be clearly defined and recorded. This is to ensure that people receive the dose that they need when they need it. All handwritten entries on MAR charts should be signed and checked to ensure that instructions are recorded accurately The risk assessments for unguarded radiators should be reviewed to ensure that the risks are still low. The registered person should check that continence waste is being managed safely and in accordance with the Department of Health Guidance. To protect the health and safety of people living and working at the home staff should receive refresher training in safe working practice topics. 3. OP9 4. OP9 5. 6. OP19 OP26 7. OP30 Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 28 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 Heslam Homes Limited DS0000005825.V342539.R01.S.doc Version 5.2 Page 29 - 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!