Inspection on 09/12/05 for Hilbre House

This inspection was carried out on 9th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hilbre House 02/06/08

Hilbre House 05/12/07

Hilbre House 29/05/07

Hilbre House 12/12/06

Hilbre House 21/06/06

Hilbre House 28/02/06

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 Leila Mavropoulou Unannounced Inspection 9th December 2005 10:30 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.V273215.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 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 Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2005 Brief Description of the Service: Hilbre House is a large detached property overlooking the river in the Hoylake area on the Wirral. It provides support and personal care to twenty-seven service users. The accommodation is provided in single bedrooms all with ensuite facility. The home is staffed twenty-four hours and some staff have completed their NVQ level 2 &3 in Care Qualification. The home has a sitting room, large dining room and conservatory on the ground floor. All parts of the home is easily accessible by a passenger lift. The fee level at the home varies depending on the bedroom accommodated. The home has assisted baths to promote the safety and independence of the service users. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that lasted for 6 hours over two days. During this time various records were inspected such as: service users records, fire records and staff files. In addition the inspection of the building was carried out and eight service users and four staff members were spoken to individually. What the service does well: What has improved since the last inspection? What they could do better: The registered person must ensure that a competent person assesses the service user needs prior to admission, to ensure that the home is able to meet the assessed needs of the service user. A record must be kept of the assessment. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 6 The registered person must ensure that information obtained at the preadmission assessment is used to develop appropriate care plans and risk assessments to enable staff to provide the necessary care and to promote the safety of the residents. The registered person must ensure that staff records are maintained in accordance with the requirements of the Care Homes Act 2001 by obtaining two references, a Criminal Record Bureau check etc. prior to staff commencing employment in the care home. In addition a training record must be maintained of all training provided to staff. The registered person must ensure that all staff receive appropriate training for the tasks they are to perform through staff induction, which is recorded and other formal training to reflect the needs of the residents. The registered person must appoint a manager to be responsible for the dayto-day running of the care home and provide ongoing and individual supervision to staff. The registered person must develop a quality assurance system to demonstrate that the home is continually seeking to improve the quality of care provided to the service users. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5,6 The home must improve its record keeping, to promote the health and safety of residents; by ensuring that service user needs are assessed prior to admission and appropriate records are maintained and developed. EVIDENCE: Inspection of the last four admissions to the home showed that there is no consistency with the assessment of service users needs prior to admission. In some instances staff from the care home carried out pre-admission assessments and in other instances there was no evidence of an assessment undertaken. Information obtained from the assessment was not developed further into a service user plan and risk assessment to ensure continuity of care was provided to the resident; through clear instructions on how to meet the assessed needs of the service user. In addition risk assessments were not in place for identified risks to promote the health and safety of the resident and staff. In the service user files inspected copies of the Care Management Assessment were not available. Discussion with the service users and staff confirmed that they were encouraged to visit the home prior to admission. However, one service user Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 9 said that she was unable to visit, but a family member visited the home and gave her feedback about its suitability. Inspection of some service users records showed that they were given a written terms and conditions of the home. However, the home’s terms and conditions must be reviewed to include the room number to be occupied by the service users and notice of fee increase, length of notice given for fee weekly increases and any restriction the home places on the service user in respect of alcohol, drugs and smoking. The personal details of all service users must be completed fully. This includes date of admission and discharge, details of the service user GP, next of kin etc. A photograph of the service user must also be kept on file. The home does not provide intermediate care. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Service user health needs are met. However this could be improved through detailed development and regular review of the service user care plans and risk assessments. EVIDENCE: Service user plans and risk assessments were in place for the service users that had been in the home prior to September 2005 and there was evidence that they were reviewed monthly. However, service users recently admitted to the home did not have service user plan and risk assessments. Despite, this entries in the daily service users records showed that their health needs were being met through visits by the GP, district nurse input, outpatient appointments to various health clinics, regular visit from the chiropodist etc. It was observed that where necessary, appropriate pressure relieving aids are obtained after assessment by the district nurse to prevent pressure areas from developing. Inspection of the service users medication records showed that the current month’s supply of medication had not been recorded on the service users medication records. Some of the service users administer some of their own medication such as: creams, laxatives etc. However, this was not identified in Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 11 the service user plan or any action taken to minimise any identified risks. The registered person must ensure that where service users are self-medicating that a lockable space is provided in their bedroom for the storage of medication. Observation throughout the inspection showed that the service users are treated with respect and dignity through the manner in which they spoke to the residents, by knocking on doors before entering and the way in which they assisted service users with personal care. This is achieved through all accommodation provided are in single bedrooms with toilet en-suite facility. Many of the service users have a direct telephone line in their bedroom to enable them to maintain contact with family and friends in private. The home also, has a cordless phone to enable other service users to have the same right. All of the service users were well dressed and groomed as the home has a visiting hairdressing once a week, which many of the service user use and the staff at the care home carry out manicure once a week. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The service users make decisions over all aspects of their daily lives with the support of the staff and their family. EVIDENCE: The routine at Hilbre House is very flexible and the service users determine their daily routine as observed throughout the inspection. This included service users choosing where to have their meal, where to spend time and to receive their visitors, accessing community facilities independently, choice of newspapers etc. However, the review of the service user plan should reflect service users leisure interests and where necessary ensure that the less independent service users are able to access community facilities with the support of staff. Discussion with the staff and service users confirmed that they or their family manage their finances. A tour of the building showed that service users are able to bring items of furniture into the home if they wish. Observation of meal a served at lunchtime and discussion with the service users showed a high degree of satisfaction with the food served. The presentation and serving of meals allowed service user choice and promoted their independence as the meals were placed in serving bowls on the table. Records are maintained of all food provided to service users and fridge and food temperatures are maintained to promote the health and safety of the Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 13 service users. Currently, none of the service users required assistance at mealtimes. Discussion with the service users and staff confirm that the home would cater for service user that require a special diet, as currently there are two service users that have a sugar free diet. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service user protection against abuse could be improved through improved staff training and awareness of the home’s procedures. EVIDENCE: The home has a complaints procedure, which is display in a prominent position, enabling service users or their representatives to know how to make a complaint and to whom. However, the home’s complaint procedure must be amended to reflect the change in name of their regulatory body, which is the Commission for Social Care Inspection. Discussion with the staff indicated that some had an understanding of various forms abuse can take. However, they were unclear of the home’s policy on abuse and did not know about reporting incidents to the Wirral Adult Protection Team. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,24, The accommodation provided at Hilbre House promotes the emotional and psychological wellbeing of the service users, through providing a well maintained homely environment. EVIDENCE: The home is well maintained and there is evidence that the home benefits from regular decoration both internally and externally. At the time of the inspection the exterior of the home was being painted and a new kitchen was being redesigned. In addition two of the service users bedrooms have been decorated. All parts of the home are accessible by a passenger lift and the garden is easily accessible by wheelchair users. In addition the home has a call system to allow service users to obtain assistance from staff when required, grab rails, raised toilet seat etc. The home has a large sitting room, conservatory and dining area on the ground floor. In addition there is a small additional seating area by the front door, which is used by service users. All of the bedrooms are furnished to reflect the service users needs, as many of the service users have brought into the home some of their furniture to Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 16 personalise their bedroom. All of the bedrooms are of single occupancy. Inspection of the building showed that not all service user bedrooms had a lockable space. The bedrooms in the home have an en-suite toilet facility and toilets are located close to the communal areas. The home has assisted baths to promote the safety and independence of the service users. The home is centrally heated. All of the bedrooms are bright and well ventilated. There is emergency lighting throughout the home, which is tested at regular intervals. At the time of the inspection regular hot water temperatures are not recorded to ensure that the temperature of hot water at outlets used by service users are as close as possible to 43 degrees centigrade. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 The staff meets the needs of the service users. However, the safety of the service users could be improved with implementation of the home’s recruitment procedure. EVIDENCE: Discussion with staff and inspection of the daily record of the service users show that staff are aware of the needs of the service users. Observation during the inspection showed that staff access information and support from other health professionals such as: GP, District Nurse when necessary to promote the health of the service user. Discussion with the manager and staff confirmed that some staff are waiting to commence their NVQ Care Award. The home is working toward 50 of its staff group achieving the NVQ level 2 Care Qualification. The staff files show two written references, Criminal Records Bureau check, job description, photograph of the staff, and two pieces of identification are not obtained prior to staff commencing employment at the home. The staffing records must be improved to protect service users. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,36,37,38 The day-to-day management of home must be improved to promote the quality of care to the service users, through improving staff supervision and record keeping. EVIDENCE: The home has been without a registered manager since September 2005. In the interim period the registered person has been responsible for the day-today management of the home with senior carers. As a consequence staff supervision, training, maintenance of service users and staff record, risk assessments have not been completed. Discussion with the staff confirmed that they had not been given individual supervision by the manager or the registered provider. There is evidence that these records were not maintained fully when the registered manager was in post, as supervision and monthly visits whereby the registered provider inspected various records to show that they were maintained did not occur. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 19 Discussion with the registered provider indicated that the home had not developed a quality assurance system to review at intervals the quality of service provided at Hilbre House through seeking the views of the service users and others that have an input at Hilbre House such as: GP. other health professionals and family/friends of the service users. A current Public Liability Insurance certificate was displayed in the hall on the ground floor. The registered provider indicated that records are kept of all expenditure in the care home for accounting purposes. Discussion with the registered provider indicated that a business plan was being developed, which would be made available to the Commission on request. Discussion with the staff, the registered provider and inspection of the service user records show that risk assessments had not been developed for identified risks to the service users. In addition regular risk assessments are not carried out for the building to promote the health and safety of the service users and staff. The staff informed the inspector that they do receive induction when they commence employment regarding the service user needs, fire awareness and where the policies and procedures of the home could be found. However, issues discussed at staff induction are not recorded. The registered person should ensure that all staff complete the TOPPS induction within six months of commencing their employment. The home maintains a record of all accidents/incidents in the care home and where necessary the Commission is informed. However, discussion with staff confirmed that not all staff were aware of the reporting incidents regarding the service user’s welfare to the Commission. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 1 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 17 x 18 2 2 x 3 3 x 2 2 x STAFFING Standard No Score 27 3 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 3 x 1 2 2 Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP5 Regulation 5 &17 Requirement Timescale for action 28/02/06 2 OP3 14 &17 The registered person must ensure that the room number to be occupied by the service users is included in the home’s terms and conditions. Also, details of notice given of increases in weekly fees and any restrictions placed on service users regarding the use of alcohol, drugs and smoking. 28/02/06 The registered person must ensure that a competent and qualified person assesses the service user needs are assessed prior to admission to ensure that the home is able to meet the assessed needs of the service users. A copy of the pre-admission assessment must be kept on the service user file. The registered person must ensure that service user personal details information is completed and kept on file. The registered person must ensure that the home maintains an admission and discharge at the care home. The registered person must DS0000018896.V273215.R01.S.doc Version 5.0 Hilbre House Page 22 3 OP7 15 4 OP9 13 & 17 5 OP16 22 6 7 OP18 OP19 18 23 8 OP29 17 9 OP30 17 &18 10 OP31 8 ensure that a photograph is kept on file of each service user. The registered person must ensure that all service users have a current service user plan and risk assessments, which are reviewed regularly with the service user or their representative where possible. The registered person must ensure that a record is kept of service users medication received into the care home. The registered person must ensure that a record is maintained of all medication training provided to staff where it is part of their roles and responsibilities. The registered person must amend its complaints policy from NCSC to CSCI as the current regulatory body. The registered person must ensure that all staff receives training on understanding abuse. The registered person must ensure that the home conform to the requirement of the local fire authority by ensuring that the furniture stored on the landing of the stairs are removed. The registered person must ensure that all staff have two written references, two pieces of identification on their file a Criminal Record Bureau check, a job description and a terms and conditions of employment. 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: staff induction. The registered person must recruit a manager who is DS0000018896.V273215.R01.S.doc 28/02/06 28/02/06 28/02/06 28/02/06 16/12/05 30/01/06 30/01/06 28/02/06 Page 23 Hilbre House Version 5.0 11 OP33 24 &26 12 13 OP36 OP37 18 17 14 OP38 13,23, 15 OP38 37 responsible for the day-to-day management of the home. The registered person must inform the Commission of the action taken to make the appointment. The registered person must ensure that the home develop a quality assurance system to monitor the quality of care provided at Hilbre House. The registered person must visit the home monthly and compile a report on their findings regarding service user records, recruitment, service users finance etc. and forward a copy of the report to the Commission. The registered person must ensure that staff receives appropriate supervision. The registered person must ensure that the records that records relating to service users, staff and other statutory records are maintained in accordance with the Care Homes Regulations 2001. The registered person must ensure that detailed risk assessments are devised for identified risk to service users and that a risk assessment of the building is carried out to promote the health and safety of service users. The registered person must ensure that staff are aware of informing the Commission of incidents regarding the health and welfare of the service users. 28/02/06 28/02/06 28/02/06 30/01/06 30/01/06 Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP12 OP24 OP30 Good Practice Recommendations 1 2 3 The registered person should provide information about local events, which service users could access. The registered person should provide a lockable space in each of the service user bedroom to promote their right to privacy. The registered person should ensure that all staff receive at least three paid training days a year. Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hilbre House DS0000018896.V273215.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!