Inspection on 07/11/05 for Hilbre Court

This inspection was carried out on 7th November 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

Hilbre Court 12/02/08

Hilbre Court 20/06/07

Hilbre Court 20/02/07

Hilbre Court 21/06/06

Hilbre Court 01/03/06

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 Leila Mavropoulou Unannounced Inspection 7th November 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 Hilbre Court DS0000018895.V265390.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. Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 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 Care Home 14 Category(ies) of Dementia - over 65 years of age (14) registration, with number of places Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 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 28th February 2005 Brief Description of the Service: Hilbre Court is large detached property with secluded gardens to the rear of the property. Shops, the seafront and public transport are easily accessible from the home. The home provides twenty-four hour care and personal support for fourteen older persons that have a mental illness. The accommodation is provided in both single and shared bedrooms that have an en-suite toilet facility. The home has various aids and a passenger lift to promote the safety and independence of the service users. On the ground floor there are two lounges and a separate dining room. Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that lasted five hours. During the inspection two staff members were spoken to, observation of the service users, inspection of service users files, staff records and other records that are required to be kept at the care home. The building was also inspected during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Formal assessment of prospective service users must be carried out by a member of staff at Hilbre Court to ensure that the home is able to meet the service users assessed needs. In addition the home must ensure that the service user is assessed as being elderly mentally infirm and require the level of care provided at Hilbre Court. The registered person must ensure that all staff receive training on caring for the elderly with dementia and managing physical and verbal aggression. The registered person must ensure that all new staff are recruited within the home’s recruitment procedure and that all the necessary checks are obtained prior to the staff commencing employment. The registered person must ensure that all new staff is inducted into their role and that a record is kept of training provided during the induction. The registered person must ensure that all staff receive regular individual supervision and a record is kept of issues discussed during supervision. Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 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. Hilbre Court DS0000018895.V265390.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 Hilbre Court DS0000018895.V265390.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): 1 &3 Staff at the care home must assess the needs of prospective service users to ensure that the home is able to meet their needs. EVIDENCE: The home has a Statement of Purpose, which provides information about the services provided at Hilbre Court to prospective service users. The Statement of Purpose must be reviewed to show the current staffing structure and their qualifications. In addition the details of the home regulatory body must be changed to Commission of Social Care Inspections. Service users recently admitted to the care home files were inspected. They showed differences in the home’s pre-admission assessment process when a service user is admitted from another home belonging to the same provider. Discussion with the manager indicated she and staff have good understanding of the needs of the service user, as she has a high degree of contact with the other home and some of the staff work in the other home as well. Hence, information is transferred with the service user. The registered person must ensure that they undertake their own formal pre-admission assessment and ensure that there is medical assessment stating the service user needs must Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 9 be met within a care home for people with mental health needs. In addition the registered manager must ensure that a basic care plan and risk assessments are in place based on the pre-admission assessment information, prior to the arrival of the service user. This is to ensure that staff are aware of how to meet the needs of the service user and to provide continuity of care to the service user. Hilbre Court DS0000018895.V265390.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): 7,8,9,10 The service users health needs are met. However, improvements could me made through providing staff training in understanding dementia and other associated illness. EVIDENCE: Inspection of some service users files showed that their health needs are met through regular review of their service user plans, regular assessments from other health professionals such as: Community Psychiatric Nurse, service user GP, continence adviser, chiropodist etc. One of the service user files showed nutritional screening was carried out and the assessment was incorporated in the service user plan. The service users medication records have improved since the last inspection and all of the staff responsible for the administration of medication have received training. However, there were some omissions of staff signature on the service user medication chart when medication was administered. The registered person must ensure that where staff have to hand write service user medication onto their medication record that the information is countersigned by another member of staff. Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 11 The registered person must ensure that all staff receive at the beginning of their induction the home’s philosophy of care and policy and procedures regarding promoting service users rights to respect and dignity, as during the inspection it was observed that the service user right to privacy and dignity was not being promoted. As in the shared bedrooms there was no evidence of the provision of privacy screens. The Regsitered person should correct this short fall as a matter of urgency. Hilbre Court DS0000018895.V265390.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): 12,13,14,15 The service users exercise choice over their daily lives and are supported by staff to maintain contact with the community and friends/family. EVIDENCE: Observation of service users throughout the inspection showed that they are able to choose their daily routine, time of getting up, where to have their meals, where to sit and watch television or listen to music etc. The manager has started to record and obtain information from service users family of their interests prior to entering the care home in order to develop activity in the home or organise outings, which may be of interest to individual service user. The home as unrestricted visiting policy. Discussion with the staff and the manager confirmed that most of the service users have regular visitors and are taken out frequently by their relatives. The service users are able to choose where to see their visitors. In addition the home ensure that individual service users are taken out for a walk to the local shops and sometimes outings to the pub are arranged. Discussion with the manager indicated that the family members manage the service user finance as they lack capacity. The family leave a small amount of personal allowance at the home to purchase toiletries, sweets, cigarettes etc for the service users and a record and receipts are kept of all service users expenditure. Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 13 A record is kept of all food provided to the residents. The home would cater for service users that require a special diet. Currently, none of the service users require assistance at mealtimes except for prompting. Observation of the lunch-time meal showed that the mealtime is unhurried. Hilbre Court DS0000018895.V265390.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): 16,18 Service users and their family are encouraged to raise concerns they may have about the service provided. However, the records of concerns raised and the outcome must be improved. EVIDENCE: The home has a complaints procedure that is displayed in a prominent position. Discussion with the staff members on duty and the manager indicated that service user family and friends raise concerns regularly and these are addressed immediately. However, a record is not kept of the concerns or of how and when they are resolved. Since the last inspection there has been one formal complaint, which is currently being investigated. The home has various policies and procedures in place to protect service users from abuse. The registered person must ensure that all staff are aware of what action to take regarding abuse to service users or staff members. To date only two members of staff have attended a training course in managing physical and verbal aggression. The registered person must ensure that all staff receive training in managing physical and verbal aggression and understanding abuse. Hilbre Court DS0000018895.V265390.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): 19,20,21,22,24,25, The home provides a homely and relaxed environment for its service users and benefit from regular repairs and maintenance. EVIDENCE: The home benefits from regular routine maintenance and refurbishment. Since the last inspection new kitchen units and equipment have been purchased and installed. The grounds of the home were clean and tidy on the day of the inspection. The home has two lounges and a dining room on the ground floor, all of which are furnished with quality domestic furnishings. The communal rooms of the home could be used for a variety of purposes. A tour of the building showed the following minor repairs were required: the radiator panel in room 7 required fixing, the first floor bath plinth required sticking as it had come loose from the wall, Room 9 the skirting board plinth needs replacing. Some of the bedroom furniture are looking a little worn and should be replaced through a planned renewal programme of furnishings to maintain the quality of the environment. The service users are encouraged and supported to bring their personal belongings into the home to personalise their bedroom and be surrounded by items they are familiar with. Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 16 Currently, the home has one assisted bath on the ground floor and a bath with a shower on the first floor. The home currently, does not meet the ratio of assisted bathing facility to the number of service users, which is 1 assisted bath to 8 service users as, the home is registered for 14 service users. Most of the bedrooms have an en-suite toilet facility. The home has a passenger lift, grab rails, call system, emergency lighting ramp etc. to promote the safety and independence of the service users. The service users have access to all parts of the home. The home is centrally heated throughout and well ventilated. The inspector tested the hot water at outlets used by the service users. In many of the bedrooms the time taken for the hot water to reach the tap was a significant period of time, leading the inspector to form the opinion that the service users would use cold water when using the wash hand basin in their en-suite. The registered person must ensure that the hot water is stored at 60 degrees centigrade and distributed at 50 degrees centigrade to prevent risks from Legionella. Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 The health and safety of the service users could be improved through staff training and the homes recruitment procedures. EVIDENCE: Discussion and observation of staff with the service users show that they are committed to providing a high level of care to the service users. However, it would appear that the knowledge of most of the staff regarding how to cope with the service user behaviour have been obtained from working with the service users. This could be improve significantly by staff gaining an understanding of causes and the management of dementia in the elderly through formal training. The staffing level is sufficient to meet the present needs of the service users. However, the staffing level must be reviewed by the manager from time to time to reflect the changing needs of the service users. The home was clean and free from malodour at the time of the inspection. Domestics are employed to maintain the environment. Inspection of staff files showed that many of the staff did not have two written references, job description, or a Criminal Record Bureau check. This is an outstanding requirement from the last inspection. In addition the registered person should develop a form to record all training provided to staff. Currently, some staff are waiting to start their NVQ level 2 Care Award. Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 18 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): 31,33,36,37,38 The management of the home has improved. However, improvements must be made in reviewing the quality of the service to meet the changing needs of the service users. EVIDENCE: The appointment of the manager to the care home has provided direction and leadership to staff at the home. This has been evidenced through improvement in the record keeping in the care home and a general “calming” atmosphere in the home. An application has been made to the Commission to register the manager. The registered person must ensure that the home develop a quality assurance system to review at regular intervals the quality of care provided at the home that take account of the views of the service users, staff, relative and friends of service users, health professionals that have involvement in the home etc. The registered person must ensure that the monthly visits required by the provider Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 19 where they are not responsible for the day-to-day management of the home are carried out and a copy of the report is forwarded to the Commission and one is given to the manager. The registered person must ensure that the staff receive regular “one to one” supervision with the manager to ensure that the issues discussed during “hands on” supervision are formalised and where necessary training is identified and provided. The service users and their representative have access to their records, which are kept in a secure place. In general the service users records have improved. However, other records that are required to be kept in the care home must be improved such as staffing records, medication records, fire risk assessments etc. The registered person must ensure that the staff training records are maintained and a system is devised showing clearly, when staff should attend refresher training courses in areas such: first aid, fire awareness, moving and handling etc. The home maintains a record of all accidents in the care home to service users and staff and where necessary incidents are reported to the Commission. The hot water temperature at outlets used by service users should be increased to near as possible to 43 degrees centigrade. The hot water was tested at various outlets used by the service users. The inspector found that the time taken for the hot water to reach the service user bedroom took several minutes. The registered person carried out a fire risk assessment of the premises in December 2003. This must be reviewed to ensure its content remains valid. The fire certificates showed that the fire equipment are tested at regular intervals. Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 20 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x 2 3 x 2 x x STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x x 1 2 2 Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 21 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 Timescale for action 30/01/06 2 OP3 14 3 OP7 15 4 OP9 13 The registered person shall ensure that the home’s Statement of Purpose is reviewed to reflect the current staffing structure, staff qualification and details of the Commission for Social Care Inspection. The registered person must 30/01/06 ensure that service users needs are assessed prior to admission to ensure that the home is able to meet the assessed needs of the service user. The registered person must 30/01/06 ensure that the service user plan is developed and reviewed at regular intervals with the service user or their representative where possible. The registered person must 30/01/06 ensure that an accurate record is maintained of all service user medication received into the care home, administered and returned to the pharmacist. Where medication is hand written on service user medication records the DS0000018895.V265390.R01.S.doc Version 5.0 Hilbre Court Page 22 5 OP10 12 6 OP16 22 OP18 7 18 8 OP19 23 9 OP21 12 10 OP24 23 11 OP25 13 information must be countersigned. The registered person must ensure that all staff understand the home’s philosophy of care and promote service users dignity at all times. The registered person must provide privacy screens for service users in shared bedrooms to promote their privacy and dignity. The registered person must review the home’s complaints procedure to show the current regulatory body: The Commission for Social Care Inspection. The registered person must ensure that all staff receive training on managing physical and verbal aggression and understanding abuse. The registered person must ensure that the following repairs are carried out: the radiator panel in room 7 required fixing, the first floor bath plinth required sticking as it had come loose, Room 9 the skirting board plinth needs replacing. Some of the bedroom furniture is looking a little worn and should be replaced through a planned renewal programme of furnishings to maintain the quality of the environment. The registered person must provide privacy screens for service users in shared bedrooms to promote their privacy and dignity. The registered person must provide an additional supported bath to promote choice to the service users and to meet the requirement of this standard. The registered person must DS0000018895.V265390.R01.S.doc 30/01/06 30/01/06 30/01/06 30/01/06 30/01/06 30/01/06 30/01/06 Page 23 Hilbre Court Version 5.0 12 OP29 17 13 OP31 10 14 OP33 24 15 OP33 26 16 OP36 18 17 OP37 17 18 OP38 13,18,23, ensure that hot water is stored at 60 degrees centigrade and distributed at 50 degrees centigrade to prevent the risk of Legionella. The registered person must ensure that the hot water is provided locally as close as possible to 43 degrees centigrade. The registered person must ensure that two written references are obtained and Criminal Record Bureau check are obtained prior to staff commencing work in the care home. The registered person must ensure that the manager undertake periodic training to maintain their knowledge and skills. The registered person must ensure that a quality assurance system to review the quality of care provided at the care home at regular intervals. The registered person must ensure that where a manager is appointed for the day-to-day management of the home that a monthly visit is carried out to monitor aspects of the service provided and provide a report of their findings to the Commission. The registered person must ensure that staff receives appropriate supervision and training to carry out their role effectively. The registered person must ensure that accurate records are maintained in accordance with the requirements of the Care Homes Regulation 2001. The registered person must ensure that staff are appropriately trained to carry out their roles and responsibilities. DS0000018895.V265390.R01.S.doc 30/01/06 30/01/06 30/01/06 30/01/06 30/01/06 30/01/06 30/01/06 Hilbre Court Version 5.0 Page 24 The registered person must ensure that fire assessment and a building audit are carried out at regular intervals to promote the health and safety of the service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hilbre Court DS0000018895.V265390.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Hilbre Court DS0000018895.V265390.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. 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