Inspection on 12/12/06 for Hilbre House

This inspection was carried out on 12th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 House 02/06/08

Hilbre House 05/12/07

Hilbre House 29/05/07

Hilbre House 21/06/06

Hilbre House 28/02/06

Hilbre House 09/12/05

Hilbre House 18/02/05

Hilbre House 21/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Hilbre House St Margarets Road Hoylake Wirral CH47 1HX Lead Inspector Peter Cresswell Key Unannounced Inspection 12th December 2006 09:20 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 House DS0000018896.V316850.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 House DS0000018896.V316850.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hilbre House Address St Margarets Road Hoylake Wirral CH47 1HX 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 6781 Mrs Della Haynes-McManus Dr Francis Bernard McManus ** Post Vacant *** Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2006 Brief Description of the Service: Hilbre House is a large detached property overlooking the Dee estuary in Hoylake, a few minutes walk from Hoylake village with its shops and community facilities. The home has eighteen bedrooms and is registered to provide care for up to 27 residents. At the moment, though, none of the rooms are shared and 18 residents live in the home, all with single bedrooms. All of the bedrooms are en suite (including four with showers) and some are very spacious. The home has a large lounge and a spacious combined dining room and conservatory with fine views of the beach and estuary. All parts of the home are accessible by a passenger lift. In addition to the en suite showers, Hilbre House has assisted baths to promote the safety and independence of the service users. Hilbre House DS0000018896.V316850.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. On that visit the inspector spoke to the deputy manager, a member of administrative staff, the cook, care staff, several of the residents and a visiting relative. The owner (Registered Person) was on holiday but other staff helped very competently with the inspection. He toured the home, including several of the bedrooms. The inspector examined care plans and medication for three residents, and other documents relating to staff recruitment, fire safety, menus, accidents, staff meetings and residents’ activities. No pre inspection questionnaire was returned before the site visit. What the service does well: What has improved since the last inspection? What they could do better: Hilbre House’s recruitment procedures must be improved to comply with the statutory requirements and to ensure that unsuitable people are not employed in the home. Although there are signs that this is beginning to improve it is essential that the Registered Person sets up a watertight recruitment system as a matter of urgency. The home’s staffing levels still need to be reviewed to reflect the needs of the residents. At present the home does not meet the National Minimum Standard for the employment of qualified care staff. The Registered Person needs to implement a full training programme and arrange where appropriate to get the qualifications of overseas staff accredited. Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 6 Social activities and stimulation still need to be reviewed and properly documented to ensure that the residents’ needs and expectations are met. Fire safety arrangements were not adequate and were poorly recorded. It is essential that all necessary steps agreed with the Fire Officer are carried out and adhered to, in order to protect the residents from the risk of fire. 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 House DS0000018896.V316850.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 House DS0000018896.V316850.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, 5. Quality in this outcome are is adequate. Residents’ needs are assessed before admission but need to be fully recorded to ensure that all staff are aware of them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user guide was not available when the inspector visited Hilbre House. The administrator said that it was in the process of being revised by the Registered Person, Mrs Haynes-McManus. The last inspection report required that the guide be amended to include any restrictions on smoking and the use of alcohol in the home. Files for two recently admitted residents were examined. On the file for the newest resident, there was only basic information and no evidence of an assessment having been carried out. It is normal practice for the manager to assess prospective residents before admission and whilst there was no reason to believe that this had not been done in this case, there was no evidence on file. The deputy manager said that he was in the process of compiling a care plan. For the other recent admission there were some unsigned notes concerning the original enquiry Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 9 (made by a member of staff) and a transfer report from Wirral Healthcare. Fees at Hilbre House vary according to the size and facilities of the bedroom, ranging from £375 – 395. Hilbre House does not provide intermediate care so standard 6 does not apply. Hilbre House DS0000018896.V316850.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 good. Care planning at Hilbre House provides information to help staff to focus on the needs of service users. Medication is well organised, protecting the health and safety of the residents, though arrangements when residents take responsibility for their own medication need to be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are detailed care plans on file, covering the residents’ personal and social care needs. The care plans are reviewed every month by the deputy manager who records the outcome of the reviews. If any changes are needed they are entered on to the care plan. Residents receive all necessary community and specialist health care support from GPs, district nurses, outpatient appointments and a chiropodist. The inspector looked at residents’ files which showed that residents’ health needs are reviewed regularly by Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 11 specialist health professionals, either through outpatient visits or visits to the home. Staff from the care home accompany service users to outpatient appointments if necessary, though it is more usual for family members to do this. Night staff have immediate access to a file which contains a full summary of each residents’ details, to be used in the event of an emergency admission to hospital, which is good practice. Hilbre House uses a monitored dosage system for medication, with most tablets supplied in blister packs by the pharmacist. Medication is well organised and accurately recorded. A number of controlled drugs are used and they are stored in an appropriate, secure cabinet with their administration recorded and witnessed in a bound controlled drugs register. One of the residents whose medication was checked looked after her own medication. There was no record of an assessment of her capacity to do this and there is no lockable facility in the resident’s room where the medication can be securely stored. Where medication is ‘PRN’ (to be taken as required) it would be good practice to record the exact circumstances in which the medication is to be administered. All residents currently have single rooms with en suite facilities, so personal care can be given in complete privacy. Several have their own telephones and other residents can use the home’s cordless telephone. Hilbre House DS0000018896.V316850.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. Residents nutritional needs are met by well prepared meals, made with good quality ingredients, served in very attractive surroundings. There is a limited programme of activities in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was a relaxed atmosphere in Hilbre House when the inspector visited the home. Residents chose their own routines – some stayed in their own rooms, others watched television whilst some sat in the lounge or the conservatory enjoying the views over the Dee estuary. A hairdresser and manicurist visit the home regularly and both were present during the visit. The residents clearly enjoyed having their hair and nails done. Some residents told the inspector that they play bridge. An activities schedule was available but it was not dated and was very general. There are some individual records of activities but they are recorded sporadically and did not contain much information (‘watched TV; read paper’ was a typical entry). Residents would benefit from having the choice of more activities, possibly devised by a Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 13 dedicated activities organiser. The minutes of a staff meeting held earlier in the year recorded that “staff stated it (activities) was difficult because there are not enough staff”. The home does not deal with residents’ finances as they are usually dealt with by their families. All of the residents who spoke to the inspector said that they enjoyed the meals in the home, and a relative also said that the food was of very high quality. There is a printed four week menu but it was not clear that it was being followed. Residents are asked each morning if they want to have the main meal and to choose from any options available (there is always a choice of sweet for instance). There was no formal alternative to the main meal on the day of the inspection, and few on the printed menu, but the cook and the assistant manager said that if a resident does not want the main course, alternatives to suit their tastes will be provided. On the day of this site visit all of the residents chose to have the main meal (‘chicken casserole’) which was well presented. Some residents chose to eat in their rooms. The Registered Person puts great emphasis on fresh, high quality ingredients and the home therefore does not use a delivery service. A member of staff does all of the shopping so that the quality and freshness of the supplies can be checked and assured at the point of purchase. Relatives and friends of residents are welcome at any time and there were written instructions to staff to ensure that visitors are properly welcomed. This was confirmed by one relative who was visiting the home and spoke to the inspector. Hilbre House DS0000018896.V316850.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. Any complaints are taken seriously but a lack of information and training on the abused of vulnerable adults means that should an allegation of abuse be made there is a danger of it not being dealt with appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hilbre House has a complaints procedure which is available to all residents and their families. The home has received no complaints since the last inspection. The Commission for Social Care Inspection received one concern from a member of the public, via Wirral Social Services. Officers of the Commission spoke to the Registered Person about these concerns and concluded that there was no evidence to indicate that there had been any breach of the Care Homes Regulations. There was no evidence that staff have received training on the protection of vulnerable adults from abuse, and although there was a copy available of the Liverpool Adult Protection protocol, there was no copy of the equivalent Wirral procedures. Hilbre House DS0000018896.V316850.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. Hilbre House provides a comfortable and homely environment for its residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hilbre House is situated in Hoylake, directly overlooking the beach and the Dee estuary, several minutes walk from Hoylake village which has transport links to the rest of Wirral and Merseyside. The inspector visited all areas of the home, including a number of residents’ bedrooms. The large conservatory lounge and dining room has a panoramic view of the estuary. The adjacent, large TV lounge has a number of comfortable sofas and chairs. There are also a number of armchairs in the large hallway. All of the furniture is attractive, good quality, well kept and comfortable. All areas of the home were clean, attractively decorated and well maintained. The home was free of offensive Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 16 odours apart from in one corridor, where the issue needs to be addressed. The Registered Person employs a handyman and the home is well maintained. There are some minor issues of maintenance which need to be carried out. The tiling over one of the kitchen work surfaces has been removed, leaving bare, damaged plaster. This needs to be repaired with an impermeable, easily cleaned surface, such as new tiling. The toilet nearest to the lounge does not have a lock, and should be fitted with a suitable lock that can be opened from the outside in an emergency. All of the residents currently have single bedrooms with ensuite facilities, including some with showers. Some of the rooms are exceptionally spacious and all of those seen were clean, well furnished and personalised to reflect the tastes and personality of the resident. Many of the rooms also have fine views and one resident was particularly fond of her view of Hilbre Island. The carpet in bedroom 10 is lifting and stained, so it needs to be stretched and cleaned. Some of the bedrooms are large enough for sharing and the home’s registration does allow for this but the Registered Person - in line with the National Minimum Standards - will only allow rooms to be shared if both residents (such as a married couple) make a positive choice to do so. The home has a number of assisted baths. Hilbre House DS0000018896.V316850.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 are is poor. The home does not yet have adequate recruitment procedures to protect residents from the employment of unsuitable staff. The home’s staff training does not ensure that all staff are adequately trained and qualified to meet the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When the inspector visited the home there were two care staff on duty plus the deputy manager. There are normally only two care staff of any description on duty – on the day in question the assistant manager was dealing with essential administrative matters, such as updating care plans. There were 18 residents in the home and two care staff is not enough to readily meet the residents’ care needs. This was pointed out at the last inspection and the Registered Person needs to review the situation as soon as possible. Other staff were on duty, such as an administrator, cook, handyman and domestic, so residents’ other needs were well catered for. The Registered Person is required by law to complete Criminal Records Bureau checks on all staff before they start work, though in some cases they may start work under close supervision if a POVA (Protection of Vulnerable Adults) check Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 18 confirming that they are not on the POVA register has been received. Such checks were only in place for two of the staff on the rota. Whilst the inspector was there the administrator did receive confirmation that eight applications for POVA First (urgent) checks were being processed, so the situation should now begin to improve. These checks can be done by email and the Department of Health states that they are normally returned within 72 hours. It is absolutely essential and a matter of urgency that all of the appropriate checks are obtained for all staff. Until this is done there can be no certainty that unsuitable staff are not being employed. The Registered Person needs to review all of the staff files to ensure that all of the information required under the Care Homes Regulations 2001 (Schedule 2), including two written references, is available. Staff receive induction training though there was no evidence of how this is done, nor was there any evidence of other training. Staff have to be trained in fire safety, moving and handling and health and safety and this training needs to be regularly refreshed. In her response to the last inspection report the Registered Person stated that issues such as ‘fire training awareness’, moving and handling and first aid are ‘re-inforced on a regular basis during staff meetings.’ This is not adequate - such training needs to be provided by qualified trainers and must be fully documented for each member of staff. In addition the Registered Person should develop a programme of training in other essential matters such as the prevention of abuse, dealing with aggression and understanding dementia. No staff have NVQs so the home does not meet the standard of 50 of care staff with NVQ2 or better. In fact most of the care staff are from overseas and some appear to have nursing or care qualifications. The Registered Person can have these qualifications checked by a government agency, the National Recognition Information Centre for the United Kingdom (NARIC) at www.naric.org.uk which will confirm what UK qualifications they are comparable to. The deputy manager is due to start NVQ4 training in the near future. He has a nursing qualification from the Philippines but has not been able to undertake the Overseas Nurses Programme to gain UK recognition as a nurse. Such a course cannot, of course, be completed at Hilbre House, which is not registered to provide nursing care. Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38. Quality in this outcome area is poor. Adequate steps are not taken to protect the residents’ health and safety, especially by way of fire safety precautions. The home has been without a registered manager for several months. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is currently no Registered Manager at the home. Following a meeting with officers of the Commission for Social Care Inspection the Registered Person said that she would apply herself to be registered as the manager, until she was able to train up or recruit a suitable candidate. At the time of the site visit for this inspection no application had been received. There is no evidence that staff receive formal one to one supervision with a senior member of staff Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 20 at least six times a year (National Minimum Standard 36). In response to this point in the last inspection report the Registered Person stated that ‘a senior member of staff was always on duty’. This type of day to day supervision is quite separate from the need for formal supervision and does not meet the standard. As long as the Registered Person is not in day to day control of the home she needs to complete written monthly reports on the conduct of the home. The Fire Officer wrote to the Registered Person in March 2006 pointing out that fire doors must not be propped open and combustible material must not be stored in the stairwell. The Registered Person replied in August 2006 stating that ‘all staff have been reminded that no wedges should be used on fire doors’ and ‘combustible material from the south stairwell has been removed.’ Some fire doors were held open by electro-magnetic devices which release them if an alarm is sounded, but, despite the assurances to the Fire Officer, many others were simply propped open with wedges or other implements. Also, the stairwell was being used to store material which could catch fire. These matters must be remedied as soon as possible to ensure the safety of the residents. Fire extinguishers have been checked by a contractor but there was no evidence of the fire alarms or emergency lighting being checked since 2004. It was not clear that any up to date gas and electrical safety certificates were in place for Hilbre House, though these may have been held by another member of staff. It is essential that the Registered Person takes action to ensure that: fire safety systems are regularly checked to ensure their effectiveness and protect residents from the risk of fire; the gas and electrical safety systems are checked for safety and appropriate certification obtained; combustible material is not stored in stairwells; fire doors are not propped open unless they have an approved hold open device (such as the electro magnetic devices in use). The kitchen was clean and, on the whole, well organised. Fridge and freezer temperatures are recorded daily, though there were gaps when the cook was not on duty. Arrangements should be made for another member of staff to do the checks in those circumstances. Although the home has a copy of the Food Standards Agency programme, Safer Food, Better Business, it has not yet been put into action. The Registered Person may find that this system would reduce paperwork whilst still protecting food safety. The Environmental Health Officer will be able to offer detailed advice on this system. A number of items in the dry food store were out of date, by several years in some cases. These were mainly spices and flavourings but the dry stores need to be checked thoroughly for any items beyond their use-by date, cleaned, and re-organised so that it is easy to routinely check for out of date items. Hilbre House does not yet have a quality assurance system in place, though the Registered Person is in regular contact with relatives of the residents, who regularly visit the home. Accidents are recorded in an appropriate accident book, but to fully comply with the Data Protection Act the numbered forms Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 21 should be removed from the book and retained in loose leaf in a separate file. Also, serious injuries or events which adversely affect the well being or safety of any residents must be reported to the Commission for Social Care Inspection. This includes any occasion when a resident has to be taken to an Accident and Emergency Department. The Commission can provide suitable advice if necessary, including a pro forma which can be used. Hilbre House DS0000018896.V316850.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 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x 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 x 18 2 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 1 x 2 N/A 3 1 2 1 Hilbre House DS0000018896.V316850.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 OP5 Regulation 5 &17 Requirement Any restrictions placed on service users regarding the use of alcohol, drugs and smoking must be included in the Service User Guide (Originally required by 28/08/06) The Registered Person must arrange for the needs of any residents to be properly assessed and recorded. The Registered Person must make arrangements for the safekeeping of medication and must therefore ensure that where a resident wishes to administer his or her own medication: * a risk assessment is completed and recorded; * the resident has a lockable space in which to retain that medication. The registered person must ensure that all staff receive training on: * understanding abuse. * the management of physical DS0000018896.V316850.R01.S.doc Timescale for action 31/01/07 2. OP3 14 31/03/07 3. OP9 13(2) 31/03/07 4. OP18 18 31/03/07 Hilbre House Version 5.2 Page 24 and verbal aggression. (Originally required by 28/08/06) 5. OP19 23(2) The Registered Person shall keep 30/04/07 the home in a good state of repair and must therefore: *fit an appropriate lock – openable in an emergency from the outside - to the toilet nearest the lounge; * repair the identified wall in the kitchen with an appropriate surface; * clean and if necessary stretch the carpet in the identified bedroom. The registered person must 28/02/07 ensure that at all times suitably qualified and competent persons are working in the care home in such numbers as appropriate for the health and welfare of service users. (Originally required by 15/08/06) The registered person must 31/12/06 ensure that all staff have two written references, a Criminal Record Bureau check, and a terms and conditions of employment. (Originally required by 30/08/06) The registered person must ensure that all staff receive the necessary training to carry out their roles and responsibilities and that a record is maintained of all training provided to staff such as: induction, moving and handling, first aid. The registered person must appoint a manager who is responsible for the day-to-day management of the home. DS0000018896.V316850.R01.S.doc 6. OP27 18 7. OP29 17 8. OP30 17 &18 31/03/07 9. OP31 8 31/01/07 Hilbre House Version 5.2 Page 25 (Originally required by 30/08/06) 10. OP33 26 The Registered Person must visit 31/03/07 the home monthly and compile a report on their findings regarding service user records, recruitment, service users finance etc.. (Originally required by 30/08/06) The Registered Person must 31/03/07 ensure that staff receive appropriate supervision. (Originally required by 30/08/06) The Registered Person must 31/12/06 inform the Commission for Social Care Inspection of any event in the home which adversely affects the well-being or safety of a service user and must therefore report the Commission any incident which requires a resident to attend an Accident and Emergency Department for treatment. The Registered Person must take 31/01/07 adequate precautions against the risk of fire and must therefore: * remove combustible material from the identified stairwell; * ensure that fire doors are only propped open if an approved hold-open device is used; obtain gas and electrical safety certificates; * ensure that staff are trained in fire safety; * ensure that fire safety equipment is regularly checked and that those checks are recorded. The Registered Person must ensure that unnecessary risks to health and safety are eliminated and must therefore ensure that DS0000018896.V316850.R01.S.doc 11. OP36 18(2) 12. OP37 37 13. OP38 23(4) 14. OP38 13(4) 31/12/07 Hilbre House Version 5.2 Page 26 15. OP38 13 any foodstuffs that are beyond their use-by date are removed and fridge/freezer temperatures are checked every day. The Registered Person must provide training to staff to promote residents’ health and welfare i.e. training in: fire awareness, moving and handling, first aid, and food hygiene. (originally required by 30/08/06) 30/04/07 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 OP24 Good Practice Recommendations The registered person should provide a lockable space in each resident’s bedroom to enable them, if required, to keep their medication. More staff with appropriate NVQs need to be recruited – ort existing qualifications need to be properly accredited – for the home to meet the standard of 50 of care staff to have NVQ2. Accident reports should be filed in compliance with the Data Protection Act. 2. OP30 3. OP37 Hilbre House DS0000018896.V316850.R01.S.doc Version 5.2 Page 27 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 House DS0000018896.V316850.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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