Inspection on 09/08/05 for Heslam Homes Limited

This inspection was carried out on 9th August 2005.

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 25/07/06

Heslam Homes Limited 04/01/06

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. Lancashire BB2 2TZ Lead Inspector Jane Craig Announced 09 August 2005 09:00 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 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 F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Heslam Homes Limted Address Heslam House 3 St Francis Road Blackburn Lancashire BB2 2TZ 01254 201513 Telephone number Fax number Email 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 Only Personal Care (PC) 24 Category(ies) of Old age, not falling within any other category registration, with number (OP) 24 of places Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The registered provider should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 2 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 as and when service users dependency levels increase the staffing levels are closely monitored and if necessary adjusted in response to any change. Upto and including 15 service users 08:00 - 22:00 hours Management - 1 person on duty at all times Care staff - 1 person on duty at all times 22:00 - 08:00 hours 1 person on waking watch whose duties may include a small percentage of the domestic work 1 person on call in the vicinity (on the campus or within approxiamatley 3 minutes travelling distance) Ancillary Staff Domestic - 25 hours per week Cook - 35 hours per week Upto and including 16-19 service users 08:00 - 18:00 hours Management - 1 person on duty at all times Care staff - 2 persons on duty at all times 18:00 - 22:00 hours 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 staff roster. 22:00 - 08:00 hours 2 persons on waking watch whose duties may include a 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 Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 5 Upto and including 20 - 24 service users 08:00 - 13:00 hours Management - 1 person on duty at all times Care staff - 3 persons on duty at all times 13:00 - 18:00 hours Management - 1 person on duty at all times Care staff - 2 persons on duty at all times 18:00 - 22:00 hours 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 be clearly identified on the staff roster. 22:00 - 08:00 hours 2 persons on waking watch whose duties may include a small percentage of domestic work. One of the above to be designated senior person. Ancillary staff Domestic - 35 hours per week Cook - 35 hours per week Date of last inspection 18 and 19th October 2004 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. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which meant that the residents and staff were told beforehand when the inspector would be arriving. The inspection took place over one and a half days. At the time there were 18 residents accommodated in the home. The inspector met with most of the residents. 9 agreed to talk about their experiences of living in the home and their views and comments form part of this report. Discussions were held with the registered managers and two other members of staff. A partial tour of the premises took place and a number of documents and records were viewed. Detailed notes were taken, which have been retained as evidence of the inspection findings. What the service does well: Residents talked about Heslam House as being “homely” and “the next best thing to home”. They were happy with the lack of rules about what time to get up and go to bed and one commented that they could have breakfast in bed if they didn’t want to get up. Residents and staff got on well together which made for a good atmosphere. Several residents praised the staff saying that they were “smashing” and “nothing was too much trouble for them.” There were several comments about the standard of food. Residents said they had good homemade food and plenty of it. One resident said “they have some good ideas about what to give us” Residents had opportunities to make their views about the home known. They had regular meetings with the staff and one resident confirmed that they could say anything they wanted. Residents were also asked to complete surveys and anything that they were unhappy about was dealt with. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 7 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. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 6 The statement of purpose and service users guide provide sufficient information for prospective residents to be clear about the services provided at the home. This assists them to make a decision as to whether the home is suitable to meet their needs. Residents were assessed prior to their admission, which meant that their needs were identified and understood. EVIDENCE: The statement of purpose and service user’s guide had been reviewed. The requirement and recommendation following the previous inspection had been met and both documents provided the required information. One resident said that they had moved into the home because it was near to family but they said it was nice to have some information about the home. Care management assessments and care plans were on all residents’ care files. The registered manager had also assessed some of the newer residents prior to their admission. The assessment tool used followed the activities of living model. Not all residents or their representatives received written confirmation that their needs could be met at the home. Intermediate care was not provided. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Care plans did not contain sufficient, up to date information to ensure that residents’ needs were identified and met. The lack of appropriate risk assessments and management strategies meant that residents’ health care needs might remain unmet. Care was provided in such a way as to promote residents’ privacy, dignity and independence. EVIDENCE: The care records for 3 residents were examined; others were viewed in less detail. Care plans were pre-printed and followed a specific format. This meant that they did not always address the resident’s individual needs as identified in their assessment, for example, psychological health needs. Some of the plans contained clear directions for staff to follow; others required more detail to ensure that consistent care was provided. Residents’ care needs were reassessed every month and the resident or their relative signed the review notes. The review assessments ensured that any changes in the resident’s health or personal needs were documented but these were not transferred to the care plans. This meant that some care plans contained out of date or irrelevant instructions for staff to follow. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 11 There were no specific risk assessments for falls, moving and handling, and development of pressure sores. Some plans contained brief strategies to manage these aspects of health but this was not consistent. One resident had access to pressure relieving equipment but there was no corresponding care plan to direct staff in other prevention techniques. All residents had a nutritional risk check and relevant interventions were carried out where risk was identified. All of the residents spoken to said that staff looked after their health needs very well. One said, “they look after us very well when we’re poorly.” Another talked about having the district nurse, optician and chiropodist come to see her at the home. One resident said, “We are well looked after, I feel better now than I have for years.” Residents said their privacy was respected and gave examples of staff always knocking on their bedroom door before entering, and helping them in the bath without making them feel embarrassed. Members of staff were observed attending to residents in a caring and professional manner. Personal care was carried out in the privacy of the resident’s own room or the bathroom. Two members of staff talked about the importance of basic care values such as preserving privacy, dignity, independence and choice. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The routines and atmosphere in the home met residents’ expectations. Residents’ views on the level of organised activities were mixed and there was a lack of stimulation and occupation for some residents. Residents were satisfied with the open visiting arrangements. EVIDENCE: Residents spoken with said that there were no strict rules about getting up and going to bed. One said “I get up and go to bed whenever I want, it’s very convenient.” Another said that staff brought them breakfast in bed because they didn’t like to get up too early. Several residents said that the home met their expectations. Comments included: “the home can’t be bettered, the girls are smashing, nothing too much trouble.” “It’s grand, as near to home as you can get.” “It’s homely, that’s why I came.” There were mixed views about the level of activities. One resident commented that he was able to entertain himself but there wasn’t much for others who couldn’t. Another resident said “I think they could do with a bit more to do.” A third said “I get bored sometimes with nothing to do.” Residents talked about occasional trips out, games of dominoes, watching videos and regular concerts. One said “there’s enough going on for me” and another said “we watch TV and go out in the garden when it’s nice, I don’t get bored.” Activities were discussed during residents monthly meetings but there was no activity Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 13 programme and none of the care records seen contained any specific plans to meet recreational or social care needs. Arrangements for visitors were included in the service users guide. The policy enabled residents to have visitors at any time and allowed for residents to decline to see visitors if they wished. Residents were happy with the visiting arrangements. One said “staff are very good, when anyone comes up to see me they always bring them a cup of tea.” Another said that having visitors at any time was good because her family worked or lived some distance away. None of the residents were able to use community facilities independently but some went out regularly with family or friends. Residents had regular visitors from the local churches. Lunch served at the time of the inspection looked wholesome and appetising. The records of meals showed that residents received a nutritiously balanced diet with some elements of choice. Residents’ comments about the variety, quality and quantity of the meals were all positive and included: “the food’s very good, you can have what you want” “very good home cooking, it’s one of the things I like about it here” meals are very good, all homemade food and plenty of it.” Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The complaints procedure was clear. Residents knew who to go to and said that any complaints would be listened to and acted upon. Members of staff had a clear understanding of adult protection issues, which safeguarded residents and meant that any alleged incidents would be dealt with appropriately. EVIDENCE: The complaints procedure had been reviewed since the previous inspection and stated that the Commission could be contacted at any time with regard to complaints. There had been one verbal complaint made to the home in the last year. Appropriate records of the action taken and outcomes were kept. Residents at the time of the inspection said they had no complaints but they knew who to go to if they did. One resident said “you don’t have to be afraid to approach any the staff.” Other residents said they would go to the manager or deputy and they would sort anything out. All staff had received training in the protection of vulnerable adults. Those members of staff spoken to were aware of their roles and responsibilities and how to report any alleged incidents. Written guidance and policies were available to staff and management, including the Blackburn with Darwen Adult Protection Procedures. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 22, 24, 25 and 26 Some improvements had been made to the environment but there were still some outstanding issues, which may cause a risk to residents’ comfort, health and safety. EVIDENCE: Following a recommendation at the previous inspection a plan of maintenance and renewal had been drawn up but this did not include timescales for action. There had been some improvements to the environment. 2 worn carpets had been replaced, 2 new external doors had been fitted and the stair lift had been replaced. Systems were in place to control the risk of Legionella and the recently replaced water systems complied with regulations. Work was planned to replace the patio, which was uneven and slippery. Measures must be put in place to minimise risk to residents until the work is completed. There was evidence that minor faults were identified and repairs were carried out in a timely fashion. Residents said they were satisfied with the environment. One said, “it’s a lovely house and garden.” Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 16 The home had been assessed by an independent occupational therapist with regard to equipment and adaptations to assist residents. As a result grab rails had been fitted throughout the home. Recommendations from the last environmental health inspection had been actioned. Some residents did not have staff call leads in their rooms. Reasons for this were included in their plans but there was no evidence that this was re-assessed. Residents were happy with their bedrooms. Many had been personalised and reflected the individual resident’s taste. One resident commented “I am quite happy with my room, it’s very comfortable.” As previously recommended, residents’ plans stated whether or not they were able or wanted to hold their own door keys. Residents’ preferences for lockable storage space was assessed every month and recorded on their plan. Not all radiators were guarded. A risk assessment was in place but did not take into account the individual needs of residents who may be harmed by the lack of guards. At the time of the inspection the home was comfortably heated. One resident who had complained of being cold during the last inspection had been provided with extra heating in her room. Following previous recommendations water temperatures were monitored and rectified if found to be faulty. The double glazed unit on the landing had not been replaced. Residents confirmed that the home was always clean and tidy. One said “every room is cleaned” and another said “it’s always like this, not just because you’re here.” Infection control policies were in place and staff training was planned for September. There was a separate laundry, which was tidy and organised. There were no complaints about the laundry service. One resident said, “ sometimes things get a bit mixed up but they always turn up at the finish.” Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 There were sufficient numbers of staff on duty to meet the needs of the residents. Recruitment practices provided safeguards for residents. Staff were provided with relevant training but failure to adhere to timescales may result in residents’ needs not being met or cause risks to their safety. EVIDENCE: Examination of duty rosters and other documents showed that the staffing numbers complied with the minimum agreed by the previous registration authority. The levels were exceeded for some morning shifts. Residents and staff said that there were always sufficient numbers of staff on duty to meet residents’ needs. The duty roster must be altered to clearly show what staff were on duty at any given time. Residents spoke highly of the staff. Comments included: “The staff are really friendly, they always greet me with a smile”, “I like the staff” and “they’ll do anything you ask, nothing’s too much trouble.” The files of three new employees demonstrated that all pre-employment checks were obtained before new staff commenced work. The manager did not retain evidence that a POVAfirst check had been received prior to a new employee starting work before their full disclosure was returned. All other required information and documents were retained on staff files. Discussions took place as to how the current application and reference request forms could be improved to help confirm information. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 18 All new staff went through an induction training programme covering polices and practices in the home. Those without previous NVQ training commenced a more in-depth programme that met the national training organisation specification. This generally took longer to complete than the recommended timescale, which meant that some staff had not received training in safe working practices until they had been working with residents for a number of months. The manager was waiting for information about the new foundation training standards before developing that programme. There were some opportunities for other training but the topics were limited. 50 of care staff were trained to NVQ level 2. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37 and 38 Systems were in place to review the quality of care provided, which included seeking views of residents and their relatives. Residents’ finances were handled appropriately. The lack of risk assessments for potentially hazardous practices may place residents and staff at risk of harm. EVIDENCE: The home held the Blackburn with Darwen quality assurance award. There were also in-house systems for seeking residents’ views. Dates of the monthly resident meeting were displayed. Several residents made mention of this and one said, “You can say what you want at the meetings.” Annual surveys were carried out and results were published in the service users guide. There was evidence that any issues raised in the surveys were addressed. Residents were also invited to complete a survey about the admission process. Visitors were also asked to complete surveys and any areas of concern were discussed individually. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 20 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 from the previous inspection the registered provider completed a monthly report of unannounced visits to the home. A copy of the report was supplied to the Commission. Examination of records showed that accidents were not always recorded appropriately and some accident report forms had been misplaced. Most staff training in health and safety topics was up to date or staff were booked on courses. Records of fire drills were kept. Fire alarms and emergency lighting were checked regularly. Evidence was seen of servicing and maintenance of systems, appliances and equipment. Some potentially hazardous substances were stored in residents’ bedrooms but there were no risk assessments to support this. Some environmental risk assessments were in place but there were no risk assessments for working practices. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x 2 x 3 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x 2 2 Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14(1)(d) Requirement The registered person must provide written confirmation to the resident that, following assessment, their needs can be met in the home The registered person must ensure that the residents plan of care sets out their personal, health and social care needs and how they are to be met. (timescale of 20/12/04 not met) The registered person must ensure that care plans are updated as and when changes in need occur. the registered person must ensure that care plans include risk assessments, with particular attention to falls. (timescale of 20/12/04 not met) The registered person must provide a suitable programme of activities to meet the social and recreational needs of the residents. The registered person must conduct a risk assessment and put into place measures to control the risk of harm to residents caused by the uneven patio area. Timescale for action 30/09/05 2. 7 15 31/10/05 3. 7 15 30/09/05 4. 7 13 31/10/05 5. 12 16(2) 31/10/05 6. 19 13(4) 30/09/05 Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 23 7. 25 13 8. 9. 27 30 17 Schedule 4 18 10. 37 17 Schedule 4 13 11. 38 12. 38 13 Risk assessments must be carried out in respect of unguarded radiators. The assessments must take into account the individual needs of the residents who may be harmed. The duty roster must show whether staff worked the shifts allocated. New staff must receive awareness training in safe working practices during the first few weeks of employment. The registered person must ensure that appropriate records are kept of any accident or incident affecting a resident. Risk assessments must be carried out on the potentially hazardous substances stored in residents bedrooms. The registered person must ensure risk assessments are developed in respect of the environment and safe working practices. (Timescale of 30/11/04 not met) 31/10/05 30/09/05 30/09/05 30/09/05 30/09/05 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 8 19 22 25 29 Good Practice Recommendations Care plans should include a risk assessment for development of pressure sores and directions for staff with regard to prevention techniques. The annual plan of maintenance and renewal should include timescales for action. The assessments with regard to the use of staff call leads should be reviewed every month. The replacement of the double glazed unit should be included in the maintenance and renewal plan. The registered person should retain evidence that a POVA F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 24 Heslam Homes Limited 6. 30 first check has been received before a new member of staff commenced work under supervision. The foundation training programme should be implemented. Heslam Homes Limited F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton-Le-Moors Accrington Lancashire. 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 F57 F07 S5825 Heslam House V230563 090805 Stage 4.doc Version 1.30 Page 26 - 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!