Inspection on 23/12/05 for Hillesden House

This inspection was carried out on 23rd December 2005.

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

Hillesden House 18/08/09

Hillesden House 10/09/08

Hillesden House 16/09/07

Hillesden House 08/06/06

Hillesden House 30/06/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hillesden House Mount Road Leek Staffordshire ST13 6NQ Lead Inspector Irene Wilkes Unannounced Inspection 13th December 2005 10:00 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 Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 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. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hillesden House Address Mount Road Leek Staffordshire ST13 6NQ 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) 01538 373397 Mrs Tervinder Kaur Malhotra Mr Sarbjeet Singh Malhotra Miss Jane Mansell Care Home 22 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (22) of places Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: Hillesden House is a two storey extended Victorian villa situated on a quiet road on the outskirts of Leek, being approximately 1.5 miles from the town centre. The Home provides long term and respite care provision for up to 22 older people over the age of 65 years, and six of these people may have dementia as their primary diagnosis. Communal accommodation is provided on the ground floor, comprising of three comfortable lounges and a dining room. There are also six single bedrooms on the ground floor, while the first floor offers eight single bedrooms, one with ensuite facilities, and four shared rooms. More than adequate toilet and bathing facilities are provided, offering both domestic type baths and assisted bathing. The accommodation is comfortably furnished and offers a homely environment. There are spacious grounds with adequate parking facilities to the front of the home, while there are extensive views over the surrounding countryside from the first floor windows. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a part day in December 2005, and was completed by one inspector. There are 17 people living at the home at the moment. The majority of people were spoken with briefly and six ladies had a conversation with the inspector about their life in the home. A senior care worker and two care staff were on duty on each shift. The manager was also on duty and a full discussion was held with her about the residents and the progress in the home since the last visit. A care worker was interviewed about her work and the cook also spoke about her duties. A visitor to the home also talked briefly about how she found the care of her mother at the home. The care records of three people were looked at. Other records such as staff training, medication, food and staff rotas were also seen. The home had a change of ownership some nine months ago, and this inspection also looked at how some improvements to the building and grounds that were needed were progressing. What the service does well: All of the service users spoken to praised the home and the staff. They all said that the care was good and if they were unwell the staff called the doctor straightaway. They all felt that the staff showed them respect and respected their wishes. ‘The staff are all good’ ‘The staff come quickly if we press the buzzer’ ‘They are all okay and look after us well.’ The way that care is provided in the home, such as giving medication and helping people to bathe is done well, so that people living there know that they are safe. People said that the food was good, their beds were comfortable and that they had plenty of things to do, such as art and crafts and chair exercise sessions that are provided to help keep them more flexible. As this visit was made just before Christmas, a number of ladies talked about having just been to the local church for a carol service that they had enjoyed, and they had also been making Christmas cards. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 6 Everyone said that their family and friends were always made very welcome at the home. A lady was visiting her mother who has recently moved in, and she also said that she was made welcome, and that she was happy with the way that the staff were caring for her mother. There were no complaints from any of the residents at Hillesden House during the visit, and no complaints had been received by the home since the last visit. 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. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. Standard 6 does not apply to this home. An assessment of each service users’ needs is undertaken before they move into the home. This means that service users and their relatives are reassured that the home will understand about the care that they need and the way in which it should be provided. EVIDENCE: At the last inspection visit in June of this year there were some concerns that the initial needs assessments for new service users were not being completed in sufficient detail, due largely to a change in staff responsibilities in the home. It was pleasing to find at this visit that this has now been addressed and in each of the three files sampled a thorough needs assessment had been completed and a plan of care had been subsequently developed from this. The files also showed complete admission details, referring to next of kin, GP etc. An attempt was made to discuss with a relatively new resident to the home about the admission process but she was a little confused. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 9 The manager confirmed that the Social Services Department care management assessment and care plan was always obtained for all individuals referred through the local authority. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 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 the following standard(s): Standards 7, 8, 9 and 10 The home has shown considerable improvement in the recording of the needs of the service users, and their health, personal and social care needs are appropriately met. Some attention is still required however to the recording of individual risks for each service user, and the actions taken by the home to minimise these risks. EVIDENCE: The care plans of three service users were inspected. Recordings seen in the sample of care plans examined at the last inspection had been a little disappointing and so it was pleasing to note at this inspection that improvement was evident. In each case there was detailed information for care staff about the actions that they needed to take to ensure that all aspects of the health, personal and social care needs of the service user were being met. The care plans also showed evidence of review on a monthly basis by a senior member of staff, with the involvement of the service user where possible. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 11 However, while each care plan showed that a full moving and handling risk assessment was now in place, the plans would benefit from a more extensive review of any risks presenting for each service user, such as for smoking, for those who wander due to dementia, etc. This aspect of the care plan was discussed with the manager who now understands the need for these risk assessments to be completed on an individual basis for each service user. It is a requirement of this report that full attention to the individual risks presenting for each service user is given, and that such risks are recorded, together with the strategy in place to minimise the risk as far as possible. This is a requirement of this report. Whilst the risk assessment element of the care plans must be improved, the plans showed good recording of each individual’s health needs and the action taken when any health problems were experienced, i.e. full involvement of the GP and District Nurse, hospital appointments, dental, ophthalmic etc. All of the service users spoken with said that the home were very alert to their health needs and there was never any hesitation in calling a GP should this be required. The home has appropriate policies and procedures in place related to medication. Medication receipt, handling, storage and return are appropriate. Part of the lunchtime medication round was seen and there was good practice displayed, including discreet observation of the medication being taken, and clear recording. A sample of MAR (Medication Administration Record) charts was examined and there were no gaps in recording or any other obvious anomalies. Usually at the visit to this home the majority of service users are spoken to, some in greater depth than others. At this visit several ladies who were sitting in the front lounge said that they would be happy to chat, although others in the other lounges were dozing and the decision was taken not to disturb them. The ladies spoken with all said that they were very happy in the home. One lady who likes a life and a joke said ‘They’re all right. We haven’t fallen out yet anyway!’ in a jovial manner, and then went on to say that the staff are all very good. The other ladies all confirmed this and said that the staff came as quickly as they could should they press the buzzer and that they all treated them with respect, and cared about their privacy and dignity. Throughout the visit the staff were discreetly observed assisting service users and talking to them. In every instance good practice was observed and there was a genuine rapport between the service users and the staff. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 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 the following standard(s): Standards 12 and 14 The home is run flexibly so that service users retain choice and control over their lives. This means that the self-esteem of residents remains high and that they are content. EVIDENCE: Service users were asked about their day to day lives within the home and each confirmed that they made their own choices in joining the social activities provided by the home, about the food that they eat, about getting up and going to bed, relationships and religious observance. Each explained about their preferences relating to these areas and agreed that the home did their utmost to ensure that they each led a lifestyle that they chose within the confines of a group living environment. Discussion evidenced that there is a range of leisure and social activities provided by the home, including fun mobility sessions, arts and crafts etc. A number of the ladies had just enjoyed a trip out to the local church for a carol service, and a number had enjoyed making Christmas cards. The care plans of each service user show their individual interests and the choices that they have made each month in relation to the range of activities on offer. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 13 The service users confirmed that they had a choice of food at mealtimes, but that this was reliant on them asking what was on offer that day, and then choosing an alternative if they did not feel like that particular choice at that stage. The use of a menu board or such like was discussed with the cook and the manager, as another additional means of providing this information to the service users. This is a requirement of this report. The home does not hold any personal money for individual service users, as residents are usually supported in the management of their finances by relatives. Residents confirmed to the inspector that they had been told that they could bring some personal possessions with them when they were admitted to the home, and the bedrooms that were seen were well personalised. The service users who were asked were unclear about their rights to look at their personal records, although they all said that they were sure that if they asked to do so there would not be a problem. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 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 the following standard(s): Standard 18 The policies and procedures of the home and the training of staff protect service users from abuse. EVIDENCE: The home has appropriate policies and procedures in place for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of service users. There is a Whistle-blowing Policy. There have been no reported allegations or incidents of abuse at the home. A staff member was questioned about her understanding of abuse and what she would do if she ever suspected any abusive practice in the home. She had a full understanding of what constitutes abusive practice and her responsibility to report if she ever suspected any wrongdoing. The home provides safe storage for money and valuables for each service users. The policies and procedures of the home clearly prevent the involvement of staff in assisting in the making of or benefit from a service user’s will. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 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 the following standard(s): Standards 19 and 26 Although there are several improvements still required to the environment the home is making good progress in meeting the requirements. This means that service users can be reassured that their safety is less compromised, and that the Commission’s confidence in the providers’ willingness to meet the requirements remains in place. EVIDENCE: A considerable number of environmental improvements have been required of the new owners of the home. An action plan was received from them prior to their registration setting out how the improvements would be addressed, with timescales. This was a requirement of the Commission. The last inspection in June of this year showed that pleasing progress against the requirements had been made, and an additional visit was undertaken in November, a moth prior to this unannounced inspection, to see the up to date position. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 16 The progress made on the remaining requirements, with timescales, is as follows: Fill in the swimming pool. Timescale of 12/18 months from February 2005 An estimate of costs has been received showing a greater expenditure than expected. It has been agreed that alternative measures can be considered, such as more robust safety fencing put around the swimming pool. A requirement is made to provide information about any alternative plans to make the area safe, with the proposed timescale. Fit locks on bedroom doors. It was understood at the last inspection that a rolling programme had been put in place to address this requirement. However, no locks had been fitted at this inspection. A plan, with timescales, of how the work will be completed is required. Fit guards to radiators or change to low surface temperature type. Timescale – summer, 2005 Low surface temperature radiators have been purchased and a date set for the work to be competed in January 2006. Fit thermostatically controlled radiator valves in service user bedrooms. Being addressed within the above. Make secure the steps leading to an outside balcony. Timescale: immediate Steps made secure. New ramp to replace steps to be fitted longer term. Replace carpets in identified areas. Timescale: rolling programme to start summer 2005. Rolling programme has commenced. Provide wash hand basins in the 3 remaining bedrooms. Timescale: 18 months Some plumbing issues. To be discussed. - - - - - The owners had received an additional visit letter following the November visit that required an action plan relating to these environmental improvements. The plan is to be submitted to the Commission by the end of December 2005. All areas of the home were found clean. Staff were observed following appropriate procedures to prevent the spread of infection, i.e. wearing of protective clothing, washing hands, dealing with laundry etc. it was noted, however, that the home does not have paper towels available in the bathrooms and toilets in the home, that are needed to prevent the spread of infection. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 17 The manager advised that in most bathrooms there was a stock of towels available, but accepted that this was not so in the toilet areas. It is a requirement of this report that a fully stocked paper towel dispenser is fitted in every communal bathroom and toilet. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 18 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): Standards 28 and 29 The majority of staff are qualified to NVQ 2 or above, and recruitment procedures are appropriate. This means that service users are supported and protected by adequately vetted and well-trained staff. EVIDENCE: An examination of the NVQ qualifications of care staff evidenced that eight people were qualified to NVQ 2, and three people were qualified to NVQ 3, out of a total of 16 care staff. This means that 69 of staff already have the qualification, with a further four people studying for their NVQ 2. Once these four people have completed the training and providing there are no staff changes this means that the percentage trained to NVQ 2 or above will be 94 . This is very pleasing to note. Two staff files were examined and these evidenced that comprehensive recruitment procedures are followed. Each file showed that two written references had been obtained before appointment, and that gaps in employment history had been researched. CRB enhanced clearance had been obtained in both cases. Staff had received a statement of the terms and conditions of employment and a copy of the General Social Care Council Code of Conduct. A staff member who was questioned confirmed the findings of the above had been followed in her recruitment. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 35 and 38 An experienced and conscientious manager who ensures that she meets her responsibilities in securing the health, safety and welfare of the service users manages the home. EVIDENCE: The current manager has been the manager at the home for a number of years now and also has considerable additional experience in care. She has her NVQ Level 3 qualification and has for some time been attempting to enrol on her NVQ 4 and Registered Managers Award programme at a local college. The inspector has assurances that this training will be commenced as soon as a place is available in the New Year. The manager has undertaken additional training to update her knowledge, and holds a Training for trainers award to equip her to undertake moving and handling training. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 20 In discussion the manager was knowledgeable about the needs of the service users living at Hillesden House, and has a good relationship with the new proprietors of the home, who have every confidence in her ability to run the home. For some time now the inspector has discussed with the manager the need for her to delegate some responsibilities to senior staff at the home, both to enable her to spend more time on management issues, and to provide career development for the staff. It was pleasing to note at this inspection that some delegation of duties has been introduced. The home does not retain responsibility for any service user monies, and the manager understands that other family members assist a number of residents in their financial affairs. The home does keep some possessions for safe keeping for service users and these are appropriately stored in a locked safe and records are kept of all transactions. COSHH (Control of Substances Hazardous to Health) requirements were met in terms of safe storage and the information available for staff. The home employs an outside contractor to provide all health and safety advice, including the provision of written policies, risk assessments for all safe working practice topics and associated written records of all risk assessments for the environment. As stated previously in this report, and also found at previous inspections, there is a lack of written risk assessments in place related to areas of individual need, although those for safe moving and handling have been added since the last inspection. Evidence was seen that staff receive induction and foundation training to TOPSS specification and that mandatory training is up to date. Whilst there was evidence seen that fire drills are undertaken and there was a record maintained, there was no easy way to identify if all staff have been present for the appropriate number of drills, considered to be six monthly for day staff and quarterly for night staff. It is a requirement of this report that a full record of the fire drills attended by each member of staff is maintained. It was reassuring, however, that a member of staff who was questioned could speak knowledgably about the site of fire extinguishers, procedure for fire testing etc. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 21 The Accident Records were examined and these showed a total of 45 accidents/incidents in nine months, although it must be stressed that every incident, however minor, is recorded. Examination showed that there were recurring names appearing for falls. This was discussed with the manager who was recommended to analyse the accident records on a regular basis to identify if any recurring themes were emerging. It became apparent that on a number of occasions a resident had been admitted to the accident and emergency department at the hospital but the Commission had not been informed. This was a genuine oversight on the part of the manager who had not realised that the Commission must be notified of any serious injury to a service user. The notice to the Commission of any death, (these are reported to the Commission) illness and any other significant event, as listed in the regulations is a requirement of this report. The records maintained in the home for servicing of equipment, maintenance checks etc. were not available at the time of the inspection. Dates must be supplied to the Commission of the servicing of all hoists, chair lift, PAT (portable appliance testing). This is a requirement of this report. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 22 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 23 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. 1 Standard OP7 Regulation 13(4) b Requirement Ensure that any areas of risk relating to each individual service user are appropriately assessed and recorded. Provide a menu board in the home and ensure that each day’s menus are correctly shown, to include advice that an alternative choice is available Provide an action plan as identified in the additional visit letter of 10 November visit, to the timescale identified therein Provide paper towel dispensers and paper towels in every communal bathroom and toilet. Maintain a record of all fire drills to identify that each member of staff working days attends two fire drills each year, and night staff attend four fire drills. Provide the Commission with the dates of the servicing of the hoist, chair lift and Portable Appliance Testing Provide the Commission with a written notification of any death, illness and any other significant event that takes place in the DS0000063416.V272847.R01.S.doc Timescale for action 10/02/06 2 OP12 12(3) 31/01/06 3 OP19 23 31/12/05 4 5 OP26 OP38 16(2) j 23(4) e 28/02/06 31/03/06 OP38 6 OP38 7 23(2) c 31/01/06 37 31/12/05 Hillesden House Version 5.0 Page 24 care home, in accordance with all parts of regulation 37. 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 OP33 OP38 Good Practice Recommendations Introduce residents meetings as a further means of securing service user views. Undertake a periodic analysis of the accident records to see if any patterns or trends are emerging. Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Hillesden House DS0000063416.V272847.R01.S.doc Version 5.0 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. 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