Hepworth House

Registration details

The location ID for Hepworth House is 1-4180678068.

CQC register Hepworth House to carry out these legally regulated activities. Contact us if you think Hepworth House is operating services not listed here.

Type of service

• Residential homes

Service specialism

• Caring for adults over 65 yrs
• Dementia
• Physical disabilities
• Sensory impairments

Local authority

Bedford

Monitored services

CQC register Hepworth House to carry out the following legally regulated services here:

Accommodation for persons who require nursing or personal care

Mr Asgerali Mawani is responsible for these services.

Mrs Sharon Lisa Narbett is the registered manager for these services at this location.

Terms of this registration relating to carrying out this regulated activity

The registered provider must not provide nursing care under accommodation for persons who require personal or nursing care at Hepworth House.

The registered provider must only accommodate a maximum of 20 service users at Hepworth House.

The registered provider must not admit any new service user to Hepworth House without the prior written agreement of the Commission. This includes any new service user admission requests, any respite or emergency admissions of service users, any readmissions of previous service users, or where service users return to the location following admission to hospital.

The registered provider must ensure that all service users’ care needs are reviewed immediately and a copy of this review to be sent to the Commission by 4:00pm on 21 January 2025. The review must:
a. Identify immediate risks associated with service users care needs and inform an urgent review and updating of care plans and risk assessments where long term medical conditions are identified. These need to include risks in relation to pressure area care, moving and handling needs and equipment, falls and supporting people with emotional distress.
b. Ensure escalation to appropriate medical professionals takes place where necessary.
c. Identify where care plans, risk assessments and health monitoring records are missing for medical conditions and put these in place immediately.
d. Ensure service users have personalised care plans and risks assessments in place.

The registered provider must by 4:00pm on 21 January 2025 implement systems to:
a. ensure the timely identification of safeguarding incidents including any allegation or evidence of abuse and ensure such incidents are investigated and notified to the relevant local authority safeguarding teams;
b. identify, monitor and reduce restrictive practices. This must include oversight of restrictive practice in real time to ensure staff are following individual service users care plans to prevent them from becoming distress and/or support them at times of distress and least restrictive practice are used;
c. ensure the timely identification of safeguarding incidents including any allegation or evidence of abuse and ensure such incidents are investigated and notified to the relevant local authority safeguarding teams;
d. ensure accidents and incidents are appropriately identified, reported, recorded and managed. This must include overview of any themes and trends that have been identified, immediate actions taken, lessons learnt and actions taken to reduce incidents and accidents. Consideration and actions to address the emotional and psychological impact on service users must be addressed;
e. ensure time sensitive medications are administered correctly.

The registered provider must ensure by 4:00pm on 23 January 2025, they have reviewed the training needs, qualifications and competency of all staff who deliver care, including agency staff, in relation to:
a. identifying and responding to safeguarding concerns
b. supporting service users to prevent distress and supporting at times of emotional distress
c. understanding the appropriate use of restraint techniques
d. recognising and reporting unexplained injuries
e. recognising and reporting restrictive practices
f. training on the Mental Capacity Act 2005
The registered provider must demonstrate and provide evidence of what actions have been taken to ensure staff have the correct skills and competency required.

The registered provider must by 4:00pm on 21 January 2025 ensure effective quality assurance processes are established and implemented to improve the way you assess, monitor and improve the quality of the service and protect service users from the risk of harm. Evidence of your quality assurance framework must be submitted to the Commission within five days of the date of this notice. Thereafter, the registered provider must send a report to the Commission on the first day of each month with details of completed quality monitoring audits and checks. This must include areas covered, your findings and any responsive actions, clearly identifying who is responsible and the timescales for this.

By 4:00pm on 24 January 2025, the registered provider shall provide a report to the Commission setting out a summary of the audit and reviews confirming compliance with the above conditions. Thereafter, on the first day of each month the registered provider must submit a monthly report to the Commission about the outcome of the review and audits. This report must include actions taken as a result of the reviews and audits to ensure any risks identified have been assessed and mitigated appropriately. This report must specify when the actions have been completed and highlight those outstanding actions along with details of who is responsible to ensure that the risks are mitigated.