Inspection on 05/12/07 for Hilbre House

This inspection was carried out on 5th December 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 29/05/07

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 5th December 2007 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 House DS0000018896.V355938.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.V355938.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.V355938.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th May 2007 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 in single bedrooms. All of the bedrooms have en suite facilities 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 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.V355938.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 by the lead inspector and Mrs Jennifer Tweedle, a CSCI Regulation Manager. We toured the home and talked to a number of residents and several staff, including the assistant manager. We also spoke to a care consultant who is being employed by the owner. We 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 far 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 improved very slightly 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 have improved but some aspects still need to be reviewed to reflect the needs of the residents. The social history of residents should be recorded in more depth and a range of suitable activities provided. At present Hilbre House does not meet the National Minimum Standard for the employment of qualified care staff and does not have an adequate staff training programme. Hilbre House DS0000018896.V355938.R01.S.doc Version 5.2 Page 6 The Registered Person needs to implement a full training programme and arrange where appropriate for the qualifications of overseas staff to be accredited. Although the home’s fire prevention measures have improved there are still some aspects which require improvement to fully protect residents. 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.V355938.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.V355938.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, 2, 3, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents may not be able to make an informed choice as there is not have sufficient written information about the home. In some cases needs may not be met as not all pre admission assessments contained appropriate information. EVIDENCE: A service user guide is now available but still does not include details of the home’s policies on smoking and the consumption of alcohol. The copy supplied to the Commission appeared to be a draft as it had the name of another home in it and needed some work to finalise it. A Statement of Purpose has been prepared but still does not include all of the matters set out in the Care Homes Regulations. It states that the home has a Registered Manager, which at the time of the inspection was not the case. Hilbre House DS0000018896.V355938.R01.S.doc Version 5.2 Page 9 We examined a number of case files and found that in general people had been properly assessed before moving to Hilbre House. However, the assessment for one recent respite admission did not record relevant issues such as the use of alcohol and the level of confusion. This resident had disappeared from the home on the first evening in the home and was found some distance away on the front. A fuller assessment may have helped to prevent this. Hilbre House does not provide intermediate care so Standard 6 does not apply. Hilbre House DS0000018896.V355938.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. This judgement has been made using available evidence including a visit to this service. Care planning at Hilbre House provides information to help staff to focus on the needs of service users, though there should be more emphasis on residents’ social needs . Medication is well organised, protecting the health and safety of the residents. EVIDENCE: Each person has a care plan which is now kept on computer, making it easier to update. The plans are reviewed each month and a record is kept. The plans examined had been reviewed the week before the inspection and the date for the next review was on file. The plans covered the needs of the residents appropriately though there was little information about activities that they enjoyed. 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 DS0000018896.V355938.R01.S.doc Version 5.2 Page 11 Night staff have 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. Appropriate referrals had been made to community and specialist health services such as GPs, district nurses and a hospital chiropodist. Good records were kept of visits by and contact with health professionals. Medication Administration Record (MAR) sheets were clear and methodically completed. A daily count is made of medicines which are not in the Monitored Dosage System (where tablets are supplied in dedicated blister packs). Specimen signatures of staff who administer medication were on file and tallied with those on the MAR sheets. The assistant manager has prepared guidelines for the administration of PRN (‘as required’) medication. We observed staff administering medication and it was carried out appropriately. Nobody currently looks after their own medication but the assistant manager has put a risk assessment tool in place for any one who wants to do so. Some medication was found in an unlocked cabinet in a communal area and was removed before the site visit had ended. All people living in the home currently have single rooms with en suite facilities and there are no plans to reintroduce sharing of rooms (unless two people such as married couples or partners especially want to share). Personal care can be therefore be given in complete privacy. Several people have their own telephones and others can use the home’s cordless telephone. Hilbre House DS0000018896.V355938.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. This judgement has been made using available evidence including a visit to this service. Residents’ nutritional needs are met by well prepared meals, made with good quality ingredients, served in very attractive surroundings. The part time activities organiser has begun to help meet residents’ recreational needs and choices but not all social and recreational needs are met. EVIDENCE: Residents at Hilbre House tend to choose their own routines – when we visited, some were in their own rooms, others were in the main lounge whilst some sat in the conservatory. There is a part time activities organiser who works twelve hours a week. The record of activities that people had taken part in was not detailed and did not give a picture of a full range of social activities that people enjoyed. We were told that the owner’s minibus was now available again for trips out. There was a list available of possible venues for such trips, including their accessibility. 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 for some residents and keeps a record of when money is given to them and receipts for any money spent on their behalf. Hilbre House DS0000018896.V355938.R01.S.doc Version 5.2 Page 13 Those people who spoke to us said that they enjoyed the meals in the home. The home keeps a record of past menus. There was no set choice for the main course at lunchtime but a member of staff told us that if anyone did not like what was on offer, the cook would prepare something to their taste. There is always a choice of sweet and residents are asked before lunch what they would like. On the day of this site visit there were three sweets on offer, all of them home made. Vegetables are put on each table in serving dishes and the tables were well presented, which helped to give the mealtime a homely atmosphere. People told us that they had enjoyed their lunch. There is normally a choice of lighter meals or sandwiches at tea time when, again, there is 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. There were no visitors during this site visit. Hilbre House DS0000018896.V355938.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 adequate. This judgement has been made using available evidence including a visit to this service. Although adult protection policies and protocols are available, a lack of 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. EVIDENCE: Hilbre House has a complaints procedure which is available to all residents and their families. The home had 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. There were a copies available of the safeguarding adults protocols for Liverpool and Wirral. Hilbre House DS0000018896.V355938.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, 23, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hilbre House provides a comfortable and homely environment for its residents. EVIDENCE: Hilbre House is in Hoylake, directly overlooking the shore and the Dee estuary. It is several minutes walk from Hoylake village which has transport links to the rest of Wirral, Merseyside and Cheshire. We visited all areas of the home, including some people’s bedrooms. The large conservatory/lounge and dining room has a panoramic view of the estuary and Hilbre Island. It has recently been fitted with an attractive wood laminate floor covering. The adjacent, large TV lounge has a number of comfortable sofas and chairs. There are also a number of armchairs in the large hallway and a group of residents were sitting there chatting during our visit. All of the furniture is attractive, good quality, well kept and comfortable. Hilbre House DS0000018896.V355938.R01.S.doc Version 5.2 Page 16 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. However, 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. Both of these points were raised following the last inspection and should be attended to promptly. All of the residents currently have single bedrooms with ensuite facilities. 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. 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. One resident did complain of the cold and her central heating radiator was not working. The assistant manager attended to this straight away. The home generally was warm. Hilbre House DS0000018896.V355938.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. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: On the day of the site visit for this inspection there were two care staff plus the assistant manager on duty, as well as administrative staff. The owner was preparing the meal as the new chef was on leave. The rota indicated that there are now normally three care staff (including the assistant manager) on duty between 8am and 6pm . There are, however, only two care staff on duty from 6 – 10pm which still falls short of the staffing levels indicated as appropriate by the Commission for Social Care Inspection in a letter dated 16 September 2004. This may have been a factor in the failure to notice that a resident was missing one evening, as described in section 1. There should be three care staff on at all times during the day. At night there is one waking member of staff and one sleeping in on the premises. 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 all 20 staff employed at the home were checked. A valid Criminal Records Bureau certificate was in place for only eleven of these staff and five of these had started work before a CRB had been obtained. Hilbre House DS0000018896.V355938.R01.S.doc Version 5.2 Page 18 There was no evidence of POVA First checks. The Registered Person (owner) 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 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 were very few references in place for staff. Similar issues have been identified at previous inspections and there has only been a marginal improvement since the last inspection. Until proper checks are carried out there can be no certainty that unsuitable staff are not being employed. The Registered Person must 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. When agency staff are used the owner must ensure that appropriate checks have been carried out on them by the agency. We were told (after the site visit) that some of the staff are employed via an agency, but this was not clear from the records. In any event, if agency staff are used the it is still the responsibility of the registered person to prove that the appropriate checks have been carried out. Staff receive induction training and this is recorded but there was no evidence of other training apart from some training on moving and handling and medication, which is done by video training followed up by questionnaires. 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 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 (as has been done for the assistant manager, who has a nursing qualification from the Philippines). The assistant manager is registered on a course for an NVQ4. He has identified staff training needs through one to one supervision and it is important that a full training programme is now put in place. Hilbre House DS0000018896.V355938.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, 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has been without a registered manager for several months. Adequate steps are not taken to protect the residents’ health and safety, especially by way of fire safety precautions. EVIDENCE: Hilbre House still does not have a Registered Manager. Following a meeting with officers of the Commission for Social Care Inspection in 2006 the owner 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 consultant acting for the owner said that it was intended to submit an application to register a manager in the very near future. The Commission has been told similar things before and they have not happened. In the meantime the home remains without a Registered Manager. Hilbre House DS0000018896.V355938.R01.S.doc Version 5.2 Page 20 The failure to carry out proper checks on staff is an indication that whilst there is a great deal of good practice in the home, it is not being managed adequately. This is an issue for which a Registered Manager would be expected to take responsibility but may be beyond the remit of the exiting assistant manager (also described in one document as the ‘floor manager) The assistant manager has started a programme of regular one to one staff supervision and is keeping a record of the meetings. The Fire Officer wrote to the Registered Person (owner) in March 2006 pointing out that fire doors must not be propped open and combustible material must not be stored in the stairwell. The owner 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.’ During this visit we noted that some fire doors were held open by approved electromagnetic devices which release them if an alarm is sounded. However, despite the assurances to the Fire Officer, many others were simply propped open with wedges or other implements. This had been noted at the two previous inspections also. Fire doors must only be propped open if they are held by an approved hold-open device. Otherwise they are ineffective as fire doors and vulnerable residents are at risk of fire. Also, when we arrived the stairwell was still being used to store material which could catch fire (for instance, cardboard boxes full of miscellaneous material). This was removed during the visit at our request but it had been there for two inspections, putting residents at risk. These matters must be remedied as soon as possible to ensure the safety of the residents. Fire extinguishers had been checked by a contractor and weekly tests of the alarm system were taking place. Gas and electrical safety certificates were in place. 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. Fridge and freezer temperatures had been checked for the previous few days but there were long periods where there were no records of any checks. The home has had a copy of the Food Standards Agency programme, Safer Food, Better Business, but it was not in evidence in the kitchen and there was still no evidence that it has been put into action. A very small number of items (flavourings) in the dry food store were out of date, by several years in some cases. 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 has been required at the last two inspections and although there were no significant out of date items on this occasion, one of the dry food stores was untidy and poorly organised. Hilbre House DS0000018896.V355938.R01.S.doc Version 5.2 Page 21 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. Not all appropriate incidents are reported to the Commission for Social Care Inspection. For instance, the disappearance at night for several hours of a new resident (see earlier sections) is plainly an ‘event which adversely affects the well-being or safety of any service user’ and should have been reported to the Commission. In fact, no notifications have been received by the Commission since the last inspection. Hilbre House DS0000018896.V355938.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 3 2 X 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 x 3 3 x 2 Hilbre House DS0000018896.V355938.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. (Originally required by 31/03/07) The registered person must 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 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. (Originally required by 28/08/06) Hilbre House DS0000018896.V355938.R01.S.doc Version 5.2 Page 24 Timescale for action 01/02/08 2. OP5 5 &17 01/02/08 3. OP18 18 01/03/08 4. OP19 12(4) The registered person must 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. (Originally required by 01/07/07) The registered person must 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 between 6 and 10 pm. The registered person must ensure that all staff have two written references, a Criminal Records Bureau check. (Originally required by 30/08/06) The registered person must appoint a manager who is responsible for the day-to-day management of the home. 01/02/08 5. OP27 18 01/02/08 6. OP29 19 01/03/08 7. OP31 8 and s.11 Care Standards Act 2000 01/03/08 8. OP38 23(4) (Originally required by 30/08/06) The registered person must take 01/02/08 adequate precautions against the risk of fire and must therefore: * ensure that fire doors are only propped open if an approved hold-open device is used; * ensure that staff are trained in fire safety; (Originally required by 31/01/07) Hilbre House DS0000018896.V355938.R01.S.doc Version 5.2 Page 25 9. OP38 13(4) The registered person must ensure that unnecessary risks to health and safety are eliminated and must therefore ensure that: * 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. (Originally required by 01/07/07) The registered person must 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. 01/03/8 10 OP33 24 01/02/08 11 OP38 37 (Originally required by 01/07/07) The registered person must 01/02/08 notify the Commission without delay of significant events in the home affecting the welfare 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. 1. 2. Refer to Standard OP12 OP30 Good Practice Recommendations The social history of residents should be recorded in more depth and a range of suitable activities provided. 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. DS0000018896.V355938.R01.S.doc Version 5.2 Page 26 Hilbre House Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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.V355938.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!