Inspection on 20/06/07 for Hilbre Court

This inspection was carried out on 20th June 2007.

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

Hilbre Court 12/02/08

Hilbre Court 20/02/07

Hilbre Court 21/06/06

Hilbre Court 01/03/06

Hilbre Court 07/11/05

Hilbre Court 01/02/05

Hilbre Court 28/06/04

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

CARE HOMES FOR OLDER PEOPLE Hilbre Court 2 Barton Road Hoylake Wirral CH47 1HH Lead Inspector Peter Cresswell Unannounced Inspection 09:15 20 and 27th June 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hilbre Court DS0000018895.V335642.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. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hilbre Court Address 2 Barton Road Hoylake Wirral CH47 1HH 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) 0151 632 2220 Mrs Delrose Haynes-McManus Miss Tracey Dawson Care Home 14 Category(ies) of Dementia - over 65 years of age (14) registration, with number of places Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of persons for whom residential accommodation (with both board and care) is provided at any one time is fourteen (14). Only elderly persons with mental disorder may be accommodated. Date of last inspection 20th February 2007 Brief Description of the Service: Hilbre Court is large detached property with a pleasant, secluded garden at the rear. The seafront, public transport and shops in Hoylake town centre are a short walk from the home. The home provides care and personal support for fourteen older persons with dementia. There are eight single rooms and three that can be shared, most of them with an en-suite toilet facility. There is a passenger lift to the first floor. On the ground floor there are two lounges and a separate dining room. A small extension at the side of the building has created some extra space in the dining room and improved laundry facilities. A further three bedroom extension is currently being built and some additional internal improvements will be made at the same time. Fees for Hilbre Court range from £385 to £450 a week. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit, followed by a return visit the following week to see the Registered Manager, who had been on holiday at the time of the original visit, and check some records. On the first day the inspector looked at all parts of the home, spoke to several residents, three staff and a health professional who was visiting the home. On the second visit he spoke to the Registered Manager and, very briefly, to the owner, Mrs Haynes-McManus. Over the two visits the inspector examined documents, including care plans, reviews, daily reports, fire safety documentation, accident reports, recruitment information, training records and medication. What the service does well: What has improved since the last inspection? What they could do better: Few of the issues raised at the last two inspections had been addressed. Pre recruitment checks on staff had not been completed, thereby leaving residents at the potential risk of being cared for by unsuitable staff. There are not yet sufficient trained staff at Hilbre Court and there is still very little staff training. The home is understaffed so the Registered Manager does most of the cooking, inevitably detracting from her management and leadership role. Some relatively minor physical improvements are outstanding from previous inspections and these are detailed in the report. However, as they are being addressed alongside the building of the extension and related internal changes, they are not the subject of requirements on this occasion. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 6 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. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 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 Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4. Quality in this outcome area is adequate. Residents are assessed before they are admitted, so that the service can meet their needs. The Statement of Purpose and service user guide are inadequate, meaning that prospective residents and their relatives do not have access to satisfactory information about the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Files of three residents admitted during 2007 were examined. Two of the files contained brief, unsigned ‘Pre admission assessments’. The third, most recent, file did not contain evidence of any pre admission assessment at all. This resident had been admitted from another care home. All of the files, including the most recent, did, however, contain detailed care plans. There were no assessments on file to indicate why the resident in question was deemed to have dementia, though presumably these do exist as they were all local authority funded. The home’s Statement of Purpose is still in draft form. The draft refers to a service user’s guide being available to ‘potential and current residents’ but the manager said that the guide was still being ‘revamped’ and no copy was available in the home. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 9 Hilbre Court does not provide intermediate care so Standard 6 does not apply. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is poor. Care plans set out how the home meets residents’ needs though the lack of reviews means that they may not always reflect the residents’ current needs. Residents’ interests are protected by the efficient storage and administration of medication, though some minor changes are needed. The privacy and dignity of all residents in shared rooms is not adequately protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were in place for the three residents whose files were examined. They had been prepared by the manager and covered areas such as sleep patterns, dressing, personal hygiene, mobility and bathing. One of the care plans included the need to ‘educate staff on manual handling’. There was no evidence of any of the care plans having been reviewed. Daily reports are made by staff - usually two a day - but there is no care plan summary in the daily reports file. This would help to kept the essential elements of the care plan at the forefront of staff’s minds. None of the residents deal with their own medication. The home uses a monitored dosage system, where most tablets are dispensed by the pharmacist in individualised blister packs. Controlled drugs are kept in a Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 11 Controlled Drugs cabinet and their administration is recorded in a CD register, with each dose being countersigned by a second member of staff. At the time of the site visit most of the drugs being administered in this way were in fact not listed as Controlled Drugs and the home may wish to check this with the pharmacist. However, the home cannot be criticised for taking additional security measures. The cases checked were found to be accurately recorded (with one exception, set out below) and all medication was securely stored. One of the medicines on a resident’s Medication Administration Record (MAR) sheet was described as being ‘private’. The manager said that this had been prescribed by a private consultant and was paid for by the resident’s family but there was no reference to this on the MAR or on the resident’s file. The medicine is a well known drug for the treatment of Alzheimer’s, and was prescribed by a medical practitioner, so there is no reason to think that the resident was at risk, but in these circumstances the home needs to fully document the process. If necessary the manager should seek the advice of the resident’s GP. This medicine had been added to the MAR sheet by hand but the entry had not been signed. Handwritten entries on MAR sheets must be signed, preferably by two people. The stocks remaining of this medicine were not consistent with the MAR sheet records. Great care must be taken in the recording of medication, especially when it is outside the normal monitored dosage system. Medication requiring refrigeration was being kept in a normal fridge in the kitchen, along with fruit juice and other food. The manager said that when the extension is completed there will be improved storage facilities and a dedicated fridge for medication. In the meantime medication kept in a kitchen fridge must be securely stored in a separate container. At the last three inspections the Registered Person has been required to put screens in all shared rooms to ensure that personal care could be provided in private. There is a screen in one such room but not in the other shared room. This situation is unacceptable and suitable screens or other measures must be put in place. One other room is considered big enough to share if residents choose to do so and although there is no screen in this room either there was only one resident living there. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. Friends and relatives are made welcome in the home, ensuring that residents can remain in touch with friends and family if they want to. There are insufficient activities to stimulate residents. A varied, well-cooked menu is provided, ensuring that residents receive a balanced, nutritious diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some activities which residents enjoy are set out in the care plans but the home does not employ a dedicated activities organiser. Activities which the residents are recorded as enjoying include looking at videos, television and make up sessions. A record is kept of activities but for recent weeks this only included ‘nailcutting’ and visits by the hairdresser. The manager said that because of residents’ dementia it could be very difficult to find activities which they enjoyed and to motivate then to take part. This is of course one of the difficulties of caring for people with dementia but many services do successfully involve them in activity. The Registered Manager should contact the National Association for Providers of Activities for Older People (NAPA – website www.napa-activities.net) as suggested at the last inspection. Some residents do join in outings with people from Hilbre House though the manager said that they often do not especially enjoy them. The fact that the home is not always adequately staffed means that care staff do not always have the time to engage the residents in suitable activities. On the morning of the first Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 13 site visit most of the residents were simply sitting in the TV lounge. The television was on but it had poor reception and nobody appeared to be watching it. The manager said that the cause of the poor reception had been identified and was being remedied. In the shared room on the ground floor a very small television was on, with a very poor, almost unwatchable picture and the volume very loud, placed on a window ledge, where neither resident could see it anyway. A dedicated activities organiser would have the time to identify activities which suit each individual. The manager said that such posts had been advertised for Hilbre Court and the owner’s other home, Hilbre House, but it had only been possible to appoint to Hilbre House for the time being. There was an orientation display in the main lounge to tell residents the day etc. Unfortunately on both days of the inspection this gave the wrong day. Orientation boards can be helpful in some circumstances but are – obviously – worse than useless if they display misleading information. Relatives and friends are always welcome in the home and one relative visited during the inspection. There is still no chef at Hilbre Court and most of the cooking is still done by the manager, with the assistance of other staff. The food prepared on the first day of the inspection was fresh and of good quality (it was not observed on the second day) and the residents said that they enjoyed the food in the home. Meals are liquidised or cut up to help residents to eat if that is needed and at a mealtime staff were observed helping a resident, though they stood over the resident whilst they did so, which is not best practice. There is usually a choice of at least two sweets. If residents do not like the main meal on offer then the manager will prepare something else for them, but she knows the residents very well and said that the (largely traditional) menu is based around their likes and dislikes The main part of the meal (e.g. a roast joint) is sometimes prepared at nearby Hilbre House, and brought to Hilbre Court by car. This arrangement has been approved by the Environmental Health Officer. A record of menus is kept and shows that a range of different meals is provided. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is poor. There is a complaints procedure to ensure that residents and other people can complain if they wish to. Staff are not trained in the Protection Of Vulnerable Adults and there is no information on the local procedures to be followed in the event of an allegation of abuse, meaning that residents’ safety is potentially at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hilbre Court has an appropriate complaints procedure. There was no copy of the Wirral inter agency procedures on the Protection Of Vulnerable Adults (No Secrets) in the home and staff had not received training in this area. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. The home is clean, comfortable, well maintained and well furnished. Some minor repairs and replacements are needed to ensure residents’ continued comfort. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hilbre Court has a homely atmosphere. The building was generally clean and well maintained though there were a number of areas which need minor repainting or repairs. The sideboard in the large lounge was still damaged and the carpet was also damaged, apparently by cigarette burns. The manager said that when the extension and alterations (see below) are complete, the main lounge will be renovated and refurnished as it is anticipated that it will be used more by the residents. A small part of the lounge is to be used for extended office space, with the old office converted into a walk in shower, as part of the changes. New chairs and tables had been bought for the dining room, providing a much improved environment for the residents. The main stair carpet needs to be thoroughly cleaned. The bedside cabinets, sofa and beds in the shared ground floor bedroom need to be replaced, and again the manager said that this room is to be renovated as part of the changes, as it Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 16 will have an en suite fitted. The furniture will be replaced as part of that process. This bedroom was not clean and the senior carer explained that the cleaner was not on duty (though she was on the rota) and in her absence the care staff have to do the cleaning. This issue is dealt with in the section on staffing. The bath near the kitchen is not boxed in, and there is a hole in the door, though again these will be affected by the building work as the bathroom will be removed to make way for the entrance to the extension. The ceiling in room 9 is still badly stained. The larger lounge is less used by the residents, partly because the smaller lounge overlooks the garden and main corridor. Residents like to see the comings and goings and be near to staff. It is also easier for staff to observe residents in this room. Both are well furnished. There is a large, attractive garden to the rear of the home. The extension to the dining room has a dining room and table in it but does not appear to be extensively used. Most bedrooms are bright and spacious, though some need some redecoration and brightening up. Some of them are personalised to reflect the tastes of the residents. Two have French windows leading on to the grounds. Some of the bedroom furniture needs to be replaced or repaired. Most of the bedrooms have ensuite toilets. Three bedrooms are available for sharing, though only two were actually shared at the time of the inspection. It is the owner’s policy that people should only share if they have clearly expressed a wish to do so (such as a married couple or partners). Anyone currently sharing should be given the opportunity to move into a single room should the opportunity arise. There are two bathrooms, both with assisted bathing equipment. The home was generally clean and odour-free. The detached garage, which had been used in part as a food store, has been demolished and a three bedroom extension to the home is being built. The building work is causing some disruption to the home but this is being kept to a minimum and the residents are not greatly affected. Indeed, one care assistant said that some of them seem to enjoy keeping an eye on the increased activity caused by the work. Plans for this work were sent to the Commission for Social Care Inspection and of course the extension cannot be used until the conditions of registration have been varied by the Commission for Social Care Inspection following an application from the registered person. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 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 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 poor. Staff were caring and hard working during the inspection but there was no evidence that all of the appropriate checks had been carried out on all staff to ensure that residents are cared for by suitable staff at all times. Staff do not receive regular training to help ensure their competence and the home does not yet have sufficient trained care staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On 16 September 2004 the Commission for Social Care Inspection wrote to the owner to advise her that there should be three care staff on duty at all times during the waking day. At the last two inspections the home did not meet this requirement. The rota for the week of the original site visit provided for three care staff (including the manager or senior carer) between 10am and 6pm, but out of those hours (early morning and late evening) there are only two carers on duty. On Sunday there were three care staff from 11am to 3 pm only. At night, which starts at 8pm in Hilbre Court, there is one waking member of staff and one sleeping in. A cleaner was on the rota for twenty hours a week but was not working on the day of the site visit, though she was on the rota to do so. Care staff are expected to do some cleaning. There has been no cook at the home for some time and most of the cooking is done by the manager. On the day of the first site visit the cooking was being done by the senior care assistant; on the second day by the manager. Staffing therefore continues to fall short of what is required and the owner needs to review the staffing situation, in particular to ensure that the Registered Manager is able to Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 18 concentrate on management duties rather than cooking and to allow care staff to concentrate on their care tasks. Staff were seen to lift a resident in an inappropriate way, in effect drag lifting her under the arms. This is not a safe way of transferring a resident and all staff must be regularly trained in moving and handling techniques. If necessary a hoist should be provided. New staff receive induction training but the only training since the last inspection has been a course on Moving and Handling for five staff from the owner’s two homes. Only three of those staff appeared on the latest rota for Hilbre Court. There has been no training in the prevention of adult abuse and none have had special training in the care of people with dementia. As the home specialises in the care of older people with dementia all staff should receive some training in the care of residents with that condition. Three care staff have NVQ3 and it is intended that others start NVQ2 training but none actually have that qualification. The report of the last two inspections pointed out that some of the overseas staff’s qualifications could possibly be officially recognised as equivalent to NVQ and the Registered Person should consult NARIC (the government agency for the recognition of overseas qualifications) at www.naric.org.uk for advice on this issue. The manager said that the owner felt that this was unnecessary as the overseas staff had nursing qualifications from their country of origin. In the absence of such recognition the home remains short of the national standard of 50 of care staff with NVQ2. Because few staff had been properly checked when the home was last inspected the inspector asked to see the recruitment records for all care staff. He was advised that he had seen these on a recent inspection of Hilbre House and the only change to that situation was that Criminal Records Bureau (CRB) checks had been sent off for four staff (a receipt was produced). Only two of those staff appear on the current rota for Hilbre Court. At the last inspection only two out of nine staff checked had valid Criminal Records Bureau (CRB) certificates and there was no evidence that the others had been checked against the Protection Of Vulnerable Adults (POVA) register. Only one member of staff had appropriate references at that time. During this inspection the manager and the owner (who called in very briefly) were unable to show that any additional checks had been obtained other than the CRBs referred to earlier. The Care Standards Act requires that new staff have a CRB check and are checked against the POVA list before they can start employment. In exceptional circumstances staff can work under supervision if POVA First (fast tracked) checks have been obtained. It is essential that the home obtains CRB checks for all new staff or clears them against the POVA list, using the POVA First system, before they are allowed to work in the home. The Care Homes Regulations 2001 also require that the Registered Person obtains two written references for each member of staff. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 19 It is quite unacceptable that the Registered Person is not ensuring that proper checks are completed on all staff before they start work at the home. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 20 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, 32, 33, 36, 38. Quality in this outcome area is poor. The home’s day-today management rightly focuses on the interests of the residents but food supplies need to be regularly checked to guarantee residents’ safety. Using a recognised food safety programme would help to ensure residents’ safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has an NVQ3 and has now started a course for NVQ4. She has a very “hands on” style of leadership and communicates her enthusiasm and commitment to her staff. She has carried out some staff appraisals but does not have a programme of regular staff supervision. She said that she does try to do this but has to fit it in with her cooking duties. The home’s draft Statement of Purpose states that the home has an annual development plan and publishes the results of service user surveys. This does not in fact appear to be the case and Hilbre Court does not have a formal quality assurance procedure. The Registered Person visits the home several times a week but still does not prepare a written report as required by the Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 21 Care Homes Regulations. In view of the absence of a quality assurance system the Registered Person should forward copies of the reports made under Regulation 26 to the Commission for Social Care Inspection. Fire safety checks are carried out though the names of staff who have received fire safety training is not recorded. The home had a gas safety certificate but no electrical safety certificate. The report by the inspecting electrician in January 2007 made six recommendations for the building to bring the building up to the appropriate regulations. These were described as Code 1 recommendations which required ‘urgent attention and must be altered without delay’. The owner said that these would be dealt with as part of the extension (some of them did relate to the now demolished garage). The home does not, therefore, have a valid electrical safety certificate. A fire safety risk assessment was in place. Some fire doors have electro magnetic closers fitted, however, the door to the most popular lounge was again propped open by a service user’s (occupied) chair on both visits. Fire doors are ineffective if they are propped open so this door – which is kept open for understandable reasons – should only be kept open using an approved holdopen device. Also, the fire door to the upstairs corridor was not closing properly and needs to be adjusted to retain its effectiveness. Some dry food stores had previously been kept in the garage, which has now been demolished to make way for the extension. Dry food stores are now kept either in the kitchen or at Hilbre House, though the amount kept has been reduced for the time being. A few things in the kitchen were beyond their use by date. On the whole these were not significant items but one large container of mayonnaise should have been used by January 2007 and a container of chilli powder (possibly not used for residents any longer) had a use-by date of 2001. It is essential that all food stocks are checked regularly to ensure that nothing is used that may not be fit for consumption. The last report from the Environmental Health Officer stated that the home needed to introduce a food safety management system, preferably the Food Standards Agency programme Safer Food, Better Business, ‘as a matter of urgency’. This has not been done and it should be introduced as soon as possible. In the meantime the fridge and freezer temperatures are being recorded every day Dirty linen has to be taken through the dining room to get to the laundry. This arrangement is far from ideal and, as pointed out in June 2006, there should be a risk assessment as to when and how this is done. No such risk assessment is in place. The manager said that staff had been told of the correct procedure, namely that laundry should only be taken through the dining area outside of mealtimes and in a container. However, staff were seen to be carrying soiled, smelly washing through the dining room whilst two residents were still having breakfast. This is both unpleasant and a health hazard. Staff must be told to stop this practice immediately and a risk assessment, with clear written instructions to staff, must be completed. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 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 2 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 x 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x x 2 x 2 Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 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 OP1 Regulation 4 Requirement The Registered Person shall ensure that the home’s Statement of Purpose and service user guide are reviewed and amended to ensure that they contain all of the matters set out in the regulations. (Originally required 7/11/05). The Registered Person must keep the residents’ plans under review and should carry out such reviews at least once a month. (Originally required 21/06/07) The registered person must make arrangements for the recording and safe administration of medicines received in the home and therefore: * the administration of all medication must be accurately recorded so that all medication can be accounted for; * handwritten entries in MAR sheets must be signed, preferably by two members of staff; * if medication is provided DS0000018895.V335642.R01.S.doc Timescale for action 01/08/07 2. OP7 15 01/08/07 3. OP9 13(2) 01/08/07 Hilbre Court Version 5.2 Page 24 privately the source of the medication must be fully recorded and the advice of the GP must if necessary be sought. 4. OP10 12, 16(c) The Registered Person must ensure that the home is conducted in a manner which respects the privacy and dignity of the residents and must therefore provide privacy screens for service users in shared bedrooms. (Originally required 7/11/05). 01/08/07 5. OP18 13(6) The Registered Person must 27/06/07 make arrangements to prevent service users being placed at risk of harm or abuse and must therefore obtain a copy of the Wirral procedures for the protection of vulnerable adults. (Originally required 21/02/07) The Registered Person shall 01/08/07 ensure that at all times staff are employed in such numbers as are appropriate for the welfare of residents and must therefore review staffing levels including ensuring that sufficient, suitable staff are employed to prepare the residents’ meals without impinging on the direct care of the residents. (Originally required by 21/06/06) 01/07/07 The registered person shall not employ a person to work at the home unless the person is fit to do so and must therefore ensure that satisfactory CRB and POVA checks are carried out on all staff and that no staff begin work at the home under any circumstances unless they have been checked against the POVA register. All other checks DS0000018895.V335642.R01.S.doc Version 5.2 Page 25 6. OP27 18 7. OP29 19 Hilbre Court required by Schedule 2 to the Regulations must be obtained. (Originally required 07/11/05). 8. OP30 13(7); 18(1). The Registered Person must ensure that all staff receive training appropriate to the work they perform and must therefore introduce a full training programme which shall include: *training to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse; *training in the care of people with dementia. (Originally required 21/02/07). The registered person must establish a system to review the quality of care provided at the care home at regular intervals. (Originally required by 30/01/06). The registered person must visit the home at least once a month, prepare a written report on the conduct of the care home and supply a copy of the report of their findings to the Commission for Social Care Inspection. (Originally required by 30/04/06). The Registered Person must ensure that staff are appropriately supervised. (Originally required 01/11/06) 01/08/07 9. OP33 24 01/09/07 10. OP33 26 27/06/07 11. OP36 18 27/06/07 12. OP38 23(4) The Registered Person shall take 01/08/07 adequate precautions against the risk of fire and must therefore ensure that: *an up to date electrical safety certificate is obtained; * staff receive proper training in fire safety and this training is DS0000018895.V335642.R01.S.doc Version 5.2 Page 26 Hilbre Court recorded; * fire doors are kept closed unless they are held open by an approved hold-open device. (Originally required 21/02/07) 13. OP38 13(5) The Registered Person shall make suitable arrangements for the safe moving and handling of service users and must therefore ensure that all staff are suitably trained. (Originally required 21/02/07) The Registered Person shall ensure that unnecessary risks to service users are eliminated and must therefore ensure that foodstocks are regularly checked to ensure that they are not kept beyond their use-by date. (Originally required 21/02/07) Staff must be instructed to adhere to safe working practices in transporting dirty laundry through the dining room. 01/08/07 14. OP38 13(4) 01/08/07 15. OP38 13(3) 01/07/07 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. Refer to Standard OP12 Good Practice Recommendations The Registered Person should consider the appointment of a dedicated activities organiser who does not have other care responsibilities and should seek advice on the provision of activities suitable for people with dementia. Steps need to be taken to increase the number of care staff with NVQ2 in order to meet the standard of 50 of care staff with this qualification (or equivalent). DS0000018895.V335642.R01.S.doc Version 5.2 Page 27 2. OP28 Hilbre Court 3. OP38 The Registered Manager should carry out a risk assessment on the transport of dirty laundry through the dining room to the laundry. Hilbre Court DS0000018895.V335642.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Hilbre Court DS0000018895.V335642.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!