Archived: Hilbre Manor EMI Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation 12 in relation to people’s safe care and treatment.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. The processes in place to provide a good learning culture were not effective. We did not see evidence of regular supervision for staff to ensure positive feedback was received and any shared learning provided

The provider did not work well with people and health system partners to establish and maintain safe systems of care. Pre-admission assessments were completed prior to people moving into the service however these contained limited information to enable immediate support to be provided safely. Handover records we reviewed did not contain relevant information regarding a person. Whilst there were daily meetings across all internal services these were not always attended and there was no evidence to demonstrate how information at these meetings was shared with staff who were unable to attend.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. For some people the relevant safeguards were not in place, this included the Mental Capacity Act not being followed. MCA is in place to promote and safeguard decisions within a legal framework.Staff we spoke with where familiar with the adult safeguarding policy and procedures.

The provider did not work well with people to understand and manage risks. The service failed to mitigate risks to people by not assessing known risks. Lack of risk assessments placed people at risk of avoidable harm as not all staff were equipped with the information required to support people safely. Risk assessments that were in place did not contain information on what actions to take. For example, one person had a falls risk assessment in place however the actions on how to support this person to mitigate risk of further falls were not completed. This meant staff were not aware of the risk associated with people and how to respond appropriately.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We identified the service was operating a passenger lift without a valid Loler certificate, a Loler is a legal requirement to ensure the lift was safe to use. We found furniture not attached to walls, this included radiator covers, wardrobes, high chest of drawers and storage cupboards. There was a risk of these toppling over onto people particularly for people who mobilised around their room.

We identified water temperatures presented a scalding risk to people; this was discussed with the provider who took immediate action to reduce the water temperature.

Whilst this was discussed on the first day of our site visits all wardrobes and radiator covers were attached to the walls, the risk associated with the high chest of draws and storage cupboards had not been addressed. We requested the provider take immediate action to remove these risks, which they did.

We identified sources of oxygen being stored close to heat sources. By storing oxygen inappropriately placed people at risk of significant harm due to the risk of combustion.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. We identified there was not always staff on shift who were trained in first aid, this placed people at risk as staff would not have the skills to support people in an emergency. The staff were not deployed safely throughout the day and night to ensure peoples’ needs could be met in a timely manner. We observed people waiting for support to be provided for long periods of time, on one occasion we intervened and requested support.

Safe recruitment procedures were not always in place to ensure staff were recruited safely with the relevant checks in place. For example, we identified one staff member had a gap in their employment record and there was a reference missing for another staff member this was raised with the registered manager who rectified this.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We identified used incontinent aids being disposed of using incorrect procedures and placed in bins not suitable for this type of waste. We identified a damaged bedframe and some unclean bedding.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Some people were prescribed medicines to be taken ‘when required’ or with a choice of dose, but the protocols to support the safe administration of these were either not in place or were not personalised. Where there was a variable dose of medicine, there was no guidance for staff when deciding the most appropriate dose to administer. This meant people may not get their medicines consistently and at the time they were needed.