Inspection on 29/05/07 for Hilbre House

This inspection was carried out on 29th May 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 House 02/06/08

Hilbre House 05/12/07

Hilbre House 12/12/06

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 Unannounced Inspection 9:05 29th May 2007 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.V335640.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.V335640.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.V335640.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 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 twenty bedrooms and is registered to provide care for up to 27 older people. At the moment, though, none of the rooms are shared and 19 people live at Hilbre House, all with single bedrooms. All of the bedrooms are en suite (including 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 people who live there. Fees at Hilbre House range from £375 – 395 a week, according to the size and facilities of the bedroom. Hilbre House DS0000018896.V335640.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. The inspector toured the home, talked to a number of residents and several staff, including the assistant manager. He also spoke to the owner and acting manager, Mrs HaynesMcManus, who had completed a detailed pre inspection questionnaire before the site visit. The inspector examined a range of documents including recruitment files, care plans, fire safety records and medication. What the service does well: What has improved since the last inspection? What they could do better: Hilbre House’s recruitment procedures fall short of what is needed to comply with the statutory requirements and to protect residents from the employment of unsuitable people in the home. Matters have not improved since the last inspection and 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 Hilbre House does not meet the National Minimum Standard for the employment of qualified care staff and does not have a staff training programme.. The Registered Person needs to implement a full training programme and arrange where appropriate to get the qualifications of overseas staff accredited. There were some minor shortcomings in the administration of medicines. The home’s fire prevention measures are inadequate. Hilbre House DS0000018896.V335640.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 House DS0000018896.V335640.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.V335640.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 and 3. Quality in this outcome area is poor. In the absence of a service user guide prospective residents do not have ready access to all of the information they need before moving in to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No service user guide was available when the inspector visited Hilbre House. A copy of such a guide had been seen by a previous inspector who had required some amendments to it concerning any restrictions on smoking and the use of alcohol in the home. A new draft Statement of Purpose has been prepared. This is a detailed document and does state that ‘a service user’s guide will be available for current and potential residents to look at’. It then sets out the contents of the proposed guide. A service user’s guide is legally required by the Care Homes Regulations so a guide must be made available as soon as possible. In fact the draft Statement of Purpose already includes much of the information that is needed in the guide. Files for three recently admitted residents were examined. There was some evidence that they had been assessed before moving to the home and one of them confirmed that the owner had visited to make an assessment before he Hilbre House DS0000018896.V335640.R01.S.doc Version 5.2 Page 9 moved in. However, there was no record of detailed pre admission assessments, though in one case there were detailed assessment documents from Wirral Healthcare and Social Services. New residents tend not to make visits to the home before admission, as this is not always practical for older people, but do have an initial one month trial stay to see if they like living there. One resident said that his relative had been to see the home before he moved in and had described it to him. Fees at Hilbre House range from £375 – 395 a week, according to the size and facilities of the bedroom. Hilbre House does not provide intermediate care so standard 6 does not apply. Hilbre House DS0000018896.V335640.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 adequate. Care planning at Hilbre House provides information to help staff to focus on the needs of service users. Medication is on the whole well organised, protecting the health and safety of the residents, though some areas need to be improved to fully protect the safety of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are care plans on file, covering the residents’ personal and social care needs under headings such as social isolation, personal hygiene, and mobility. The plans appear to be based on a template of some sort. This is a reasonable method which can save repetitive work but the plans must be fully customised to reflect the needs of the individual concerned. One male resident was persistently referred to as ‘her’ in the care plan and another had the wrong forename in one section. The care plans are reviewed every month by the assistant 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. Residents’ files included information showing that their health needs are reviewed regularly by health professionals, either through outpatient visits or visits to the home. Staff from Hilbre House DS0000018896.V335640.R01.S.doc Version 5.2 Page 11 the care home accompany people to outpatient appointments if necessary, though more often 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. The daily reports were not especially informative (‘he is alright’ was a typical entry). Staff may be helped to improve their daily reporting if a summary of the care plan was included in the report book. Daily reports might be a suitable agenda item for a future staff meeting. Hilbre House uses a monitored dosage system for medication, with most tablets supplied in blister packs by the pharmacist. Medication is generally well organised and accurately recorded. In cases where medication is to be given ‘as required’ (PRN) there was no written guidance as to the circumstances which would lead to it being administered. The assistant manager was able to describe the appropriate procedure in each case but this should be recorded so that all staff are administering the medication correctly. In the morning a member of staff left a resident’s medication in an egg cup on the table and came back later to see if he had taken it. She did not actually observe him taking the tablets (though the inspector did). This means that it was not possible with certainty to complete the Medication Administration Record (MAR) sheet. Also, the home’s own medication policy states that all medication should be given direct to the resident from its original container or blister pack. The member of staff concerned is not listed as one of those who has been trained in the administration of medication, so she should not have been given this responsibility in the first place. Some prescribed creams were left out in residents’ rooms and they should be stored securely at all times. One resident looks after her own medication and has a suitable, secure facility in which to store it. There was no record of an assessment of her capacity to do this. 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 drugs kept in the CD cabinet is not in fact listed as a controlled drug. It can do no harm to exercise the additional precautions required for a controlled drug though it could become confusing if larger quantities were used. The manager might want to seek advice from the dispensing pharmacist. The administration of controlled drugs is signed by two members of staff though one member of staff had failed on one recent day to get a second member of staff to sign for several items. All residents currently have single rooms with en suite facilities and the owner said that she has no plans to reintroduce sharing of rooms (unless two people have an express desire to share, such as married couples or partners), so personal care can be given in complete privacy. Several residents have their own telephones and others can use the home’s cordless telephone. Hilbre House DS0000018896.V335640.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 good. Residents’ nutritional needs are met by well prepared meals, made with good quality ingredients, served in very attractive surroundings. A newly appointed activities organiser has begun to help meet residents’ recreational needs and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When the inspector visited Hilbre House there was a relaxed atmosphere in the home. Residents chose their own routines – some were in their own rooms, others were in the main lounge whilst some sat in the conservatory enjoying the views over the Dee estuary. A hairdresser goes to the home regularly and was present when the inspector visited. The residents were clearly enjoying having their hair done. Since the last inspection the home has appointed a part time activities organiser who works two days a week. She takes residents out, plays cards with them for instance) and chats to them, in groups or in their rooms. She keeps a record of who takes part in what activity though there was no record of any trips out in the owner’s minibus. There was a list of possible venues for such trips so this may develop through the summer. Two residents had recently celebrated their hundredth birthday in the home. The home does not generally deal with residents’ finances as they are usually dealt with by their families. The owner does look after the personal allowances Hilbre House DS0000018896.V335640.R01.S.doc Version 5.2 Page 13 for some residents and keeps a record of when money is given to them and receipts for any money spent on their behalf. All of the residents who spoke to the inspector said that they enjoyed the meals in the home. The home keeps a detailed record of the food served and provided copies of past menus with the pre inspection questionnaire. There is not usually a formal choice for the main course at lunchtime but the cook said that if anyone did not like what was on offer she would prepare something to their taste. There is always a choice of sweet and residents were asked before lunch what they would like. On the day of this site visit there were three sweets on offer, one of them home made, though all of them looked appetising. Vegetables are put out in serving dishes on each table and the tables were well presented, which helped to giver the mealtime a homely atmosphere. Residents were given a choice of juices with the meal and wine was available in the room though nobody appeared to have any on this occasion. Residents told the inspector that they had enjoyed their lunch. One who ate a little later said that there was never a problem if someone chose to eat at a time of their choosing. Some people chose to eat in their rooms. There is normally a choice of lighter meals or sandwiches at tea time, a typical recent example being a choice of poached egg on toast, corned beef sandwich, fried bacon on toast or grated potato cake. Again, there was a choice of sweet. The owner puts great emphasis on fresh, high quality ingredients and the home therefore does not use a delivery service. Staff do the shopping so that the quality and freshness of the supplies can be 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. Hilbre House DS0000018896.V335640.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 and 18. Quality in this outcome area is poor. A lack of information and training on the prevention and reporting of the abuse of vulnerable adults means that should an allegation of abuse be made there is a danger that it would not be 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. There was still 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 (‘No Secrets’) which will be more relevant for those who live at Hilbre House. Hilbre House DS0000018896.V335640.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 in Hoylake, directly overlooking the beach and the Dee estuary. It is several minutes walk from Hoylake village which has transport links to the rest of Wirral, Merseyside and Cheshire. The inspector visited all areas of the home, including most residents’ bedrooms. The large conservatory/lounge and dining room has a panoramic view of the estuary and Hilbre Island. 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 odours. The owners employ a handyman and the home is well maintained. 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. The adjacent toilet does have such a lock but it is broken and must be repaired. All of the residents currently have single Hilbre House DS0000018896.V335640.R01.S.doc Version 5.2 Page 16 bedrooms with ensuite facilities, including 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. One resident was keen to show the inspector some treasured personal items bought into the home. Many of the rooms also have fine views and one resident was particularly fond of her view of Hilbre Island. 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 or partners) make a positive choice to do so. The home has a number of assisted baths. The carpet in the conservatory/diner is rather worn but is about to be replaced by a new wooden floor. Hilbre House DS0000018896.V335640.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. The home does not 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: On the day of the site visit for this inspection there were two care staff on duty until 10am. There are normally only two care staff of any description on duty between 8am and 10 am and then from 6- 8pm. There were 19 residents in the home and two care staff is not enough to readily meet their care needs. This may have contributed to an untrained member of staff handing out medication (see earlier section). As long ago as 2004 the Commission wrote to the owner setting out what it regards as the minimum staffing level of three care staff on duty at all times. This was also pointed out at the last inspection and the Registered Person must review the situation as soon as possible. Other staff were on duty, such as an administrator and the cook. Hilbre House only employs one cleaner and no dedicated laundry staff, so much of this work falls to the care staff. Recruitment records for six staff employed since the last inspection were checked. A Criminal Records Bureau certificate was in place for only one of these staff, and that had been obtained after she had started work. There were no ‘POVA First’ checks in place. The Registered Person (owner) is required by law to complete Criminal Records Bureau checks on all staff before Hilbre House DS0000018896.V335640.R01.S.doc Version 5.2 Page 18 they start work, though in some cases they may start work under close supervision if a POVA (Protection of Vulnerable Adults) check confirming that they are not on the POVA register has been received in advance of the CRB check being completed (these are called ‘POVA First’ checks). There was a record of the CRB advising the owner that a number of POVA First checks could not be completed as the appropriate information had not been submitted. 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. The owner told the inspector that as she found it difficult to get POVA First checks she would in future only start people after they had received a full CRB check. This is of course the correct practice but the issue has now been raised in several inspection reports and the situation has not improved. When agency staff are used the owner must ensure that appropriate checks have been carried out on them by the agency. In addition there were no references available for most of the staff whose files were examined. Staff receive induction training and this is recorded but there was no evidence of other training apart from some training on moving and handling. The pre inspection questionnaire submitted by the owner sates that there has been no training in the last twelve months. Staff have to be trained at least in fire safety, moving and handling, adult abuse and health and safety and this training needs to be regularly refreshed. In the improvement plan submitted following the last inspection the owner stated that she was ‘re-instating the training manual’ and the assistant manager said that he was planning to introduce a full training programme. The draft Statement of Purpose states that all staff receive three days of paid training each year but this is clearly not happening at the moment. The owner must develop a programme of training in essential matters such as those set out above. The pre inspection questionnaire stated that four care staff have NVQs so the home still does not meet the standard of 50 of care staff with NVQ2 or better. In fact many 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 (for a fee) what UK qualifications they are comparable to. The assistant manager is due to start training for an NVQ4 in the near future and is now registered on a course. He has a nursing qualification from the Philippines. Hilbre House DS0000018896.V335640.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, 34, 35, 36, 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: Hilbre House still does not have a Registered Manager. Following a meeting with officers of the Commission for Social Care Inspection last year the owner had said that she would apply herself to be registered as the manager until she was able to train up or recruit a suitable candidate. No such application has been received by CSCI. The owner said that she is now planning to submit an application for the current assistant manager to be registered. This should be done without delay. There is no evidence that staff receive formal one to one supervision with a senior member of staff at least six times a year (National Minimum Standard Hilbre House DS0000018896.V335640.R01.S.doc Version 5.2 Page 20 36). The owner has carried out appraisals for all staff though this is not regular. The assistant manager said that he intends to start a programme of regular one to one supervision. 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. Such doors must only be propped open if they are held by an approved hold-open device such as ‘Dorgard’. Otherwise they are ineffective as fire doors. Also, the stairwell was still being used to store material which could catch fire (for instance, cardboard boxes full of miscellaneous material). These matters must be remedied as soon as possible to ensure the safety of the residents. These issues were also raised at the last inspection but no action has been taken, Fire extinguishers have been checked by a contractor but weekly tests of the alarm system had not taken place since 9th March. There was no evidence of fire drills or fire safety training. An electrical safety certificate was in place (valid for 12 months only) but it was not clear that all of the essential work it identified had yet been completed. A gas engineer had visited the home recently to look at the boilers but there was still no gas safety certificate in place. It is essential that the Registered Person takes action to remedy these issues as soon as possible. The home’s insurance cover was up to date and a certificate was displayed on the wall. The spacious kitchen was clean and, on the whole, well organised. There was no record of fridge and freezer temperatures being checked, though the cook said that she does check them every day that she is on duty. The home has a copy of the Food Standards Agency programme, Safer Food, Better Business, there was no evidence that it has been put into action. The local authority 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 which are not generally used for the residents, 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. This was required at the last inspection. 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 and filed in accordance with the Data Protection Act. None of the recent Hilbre House DS0000018896.V335640.R01.S.doc Version 5.2 Page 21 accidents recorded were of the kind which has to be referred to the Commission for Social Care Inspection. Hilbre House DS0000018896.V335640.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 1 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 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 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 3 3 3 2 x 2 Hilbre House DS0000018896.V335640.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 OP3 Regulation 14 Requirement The Registered Person must arrange for the needs of any residents to be properly assessed and recorded. Timescale for action 01/07/07 2. OP5 5 &17 (Originally required by 31/03/07) The registered person must 01/07/07 produce a written service user’s guide to the home. Any restrictions placed on service users regarding the use of alcohol, drugs and smoking must be included in the guide. (Originally required by 28/08/06) The Registered Person must make arrangements for the administration and 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; * an accurate record is kept of all medication which is administered; * all staff who administer medication are suitably trained DS0000018896.V335640.R01.S.doc 3. OP9 13(2) 01/07/07 Hilbre House Version 5.2 Page 24 to do so. 4. OP18 18 The registered person must ensure that all staff receive training appropriate to their work, including: * prevention of adult abuse; * the management of physical and verbal aggression; * moving and handling; * health and safety. 01/07/07 5. OP18 13(6) 6. OP19 12(4) 7. OP27 18 (Originally required by 28/08/06) The registered person must 01/07/07 make arrangements to prevent service users from being placed at risk of abuse and must therefore obtain and keep in the home for use by all staff a copy of the Wirral protocol on the reporting and prevention of adult abuse. The registered person must 01/07/07 arrange for the home to respect the dignity and privacy of the people who live there and must therefore arrange for suitable locks to be fitted to the two toilets nearest to the dining room. The registered person must 01/07/07 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 and must therefore review existing staffing arrangements. (Originally required by 15/08/06) 01/07/07 The registered person must ensure that all staff have two written references, a Criminal Records Bureau check, and a terms and conditions of employment. (Originally required by 30/08/06) 8. OP29 17 Hilbre House DS0000018896.V335640.R01.S.doc Version 5.2 Page 25 9. OP31 8 The registered person must appoint a manager who is responsible for the day-to-day management of the home. 01/07/07 10. OP36 18(2) (Originally required by 30/08/06) The registered person must 01/08/07 ensure that staff receive appropriate supervision. (Originally required by 30/08/06) The registered person must 01/10/07 establish a system for reviewing and improving the quality of the care provided at the home. This can be achieved by the introduction of a quality assurance system. The registered person must take 01/07/07 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 a gas safety certificate; * ensure that staff are trained in fire safety; * ensure that fire safety equipment is regularly checked and that those checks are recorded. (Originally required by 31/01/07) The registered person must 01/07/07 ensure that unnecessary risks to health and safety are eliminated and must therefore ensure that: * any foodstuffs that are beyond their use-by date are removed; * a food safety programme (such as Safer Food, Better Business) is introduced, which includes recording daily checks on the temperatures of the home’s fridges and freezers. DS0000018896.V335640.R01.S.doc Version 5.2 Page 26 11. OP33 24 12. OP38 23(4) 13. OP38 13(4) Hilbre House RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP30 Good Practice Recommendations There should be written guidance for any medication which is to be administered ‘as required’ (PRN). For the home to meet the standard of 50 of care staff to have NVQ2: more staff with appropriate NVQs need to be recruited; and/or existing staff need additional training, or existing (overseas) qualifications need to be properly accredited. Hilbre House DS0000018896.V335640.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.V335640.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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