Archived: Hilbre House

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.

This is the first assessment since this service was registered. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Any accidents and incidents were recorded appropriately and analysed. Where incidents had occurred, actions were put in place to help mitigate the risk of future recurrence. For example, people’s risk assessments and care plans were updated, with guidance for staff to follow.

Incidents were discussed amongst staff to enable learning, for example, lessons learned were included for discussion at staff meetings and daily handovers.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider completed an assessment of people’s needs prior to their admission to the service, to help ensure continuity of care. The manager explained that for any people who were newly admitted to the service, people’s family members were involved as much as possible to enable people to experience a seamless transition into the service.

One relative was keen to tell us about the visible improvement they had seen in their loved one’s physical and emotional well-being, since transitioning into the home from another service.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There was a safeguarding policy in place which provided staff with guidance. Staff had received training in safeguarding and told us they wouldn’t hesitate to act on any concerns.A member of staff told us, “I know the process for reporting accidents and incidents.”

People and their relatives told us they felt safe living at Hilbre House. One person commented, “Yes, I do feel safe here.” Relatives confirmed, “[Name] is kept safe - most definitely” and “Safe – yes, I have peace of mind when I go home and go on holiday as I know [Name] is safe and well cared for."

Although risks to people were identified, some people’s risk assessments required further guidance for staff on how to manage and mitigate risks to people. For example, for some people’s risk assessments which did not require a score, it was difficult to follow what action staff should take to minimise the risk.

However, we were assured the provider worked with people to understand and manage risks. Staff were knowledgeable about risks to people and provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. One member of staff told us, “I have access to care plans, they are easy to follow and provide a good level of information about people’s needs and individual risks.”

A relative told us how they thought the risks to their Mum was well managed, “Last year Mum had 2 falls, I feel they [staff] have put measures in place to help reduce that risk. She uses a trolley now, and I see staff remind her to use it.”

Personal emergency evacuation plans (PEEPS) were in place for people. A PEEP is a plan for a person who may need assistance, for example, a person with impaired mobility, to evacuate a building or reach a place of safety in the event of an emergency. Some people’s PEEPS required some additional information, such as, clarification as to what exit out of the building was the most appropriate for that person.

Accidents and incidents were analysed regularly to help identify any trends and themes and to help any preventative measures to be implemented in a timely way. We saw for one person who was at risk of falls, how the provider had introduced fall preventative measures to help minimise the risk, whilst also respecting their independence.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

An electronic signing in system was in place on entering the home. Key code pad locks were in use to prevent people from entering areas which were unsafe, such as sluice rooms and storerooms, which contained cleaning products and other potential hazardous items.

However, we observed a code to a lock on a linen storage room was visible on the door, meaning that people could potentially access this room. We spoke with the provider about this who advised the code would be removed.

Checks of the environment and equipment were up to date and certificates were in place to evidence this. The building was well maintained, and there was effective oversight of this.

A maintenance person was in post to help ensure all health and safety checks were completed. Fire exits were kept clear and fire safety checks were completed and up to date. Wet floor signs were used when floors had been cleaned and removed when floors had dried.

We observed some improvements had been recommended following a fire risk assessment of the building by an external contractor, however, the provider had already begun to put actions into place.

There was health and safety information displayed around the home including fire emergency procedures.

Easy read signage was in place to help people navigate communal areas more easily. People had access to pleasant outdoor space and a conservatory.

There were spacious and accessible garden and patio areas for people to use.

The provider ensured staff received effective support, supervision and development. Although we were assured the provider made sure there were enough qualified, skilled and experienced staff, they were not always deployed effectively.

Although staff worked well work together well to provide safe care that met people’s individual needs, we observed at busy times of the day, such as post lunch time, people were unsupervised for a length of time. For example, we observed a person located in their bedroom having to wait for assistance with their lunch. We also observed people attempting to access the lounge after lunch, some of whom required supervision with mobilising, without any staff presence, as staff were busy attending to people in their bedrooms.

We spoke to the manager about this who confirmed this was something they had already identified, and plans were in place to recruit a staff member to assist at busy times of the daysuch as mealtimes and with tasks such as the laundry. One member of staff told us, “It’s too much [the laundry] on top of our caring role and I need to spend more time with the residents.”

We also spoke with the provider about using night staff more effectively to carry out additional domestic chores; to help ease the workload of the day staff so they had more time to spend with people.

Relatives told us when they visited the home, they were made to feel welcome by staff and felt there was a consistent staff team. One relative told us, “I see the same faces and have got to know the staff well” and “Staff are around when I am there.”

Staff were recruited safely, and a programme of induction was in place to help staff settle into their role. Staff told us they had regular supervisions and had completed all their training required for their role.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Although the environment was clean and free from malodours, we observed stains to some of the communal doors on the ground floor caused by food residue. We also observed some stains to the tea trolley. We spoke to the manager about this who immediately organised for the cleaning of these areas.

Domestic staff were employed, and cleaning records were kept. There was a good stock of PPE available. Hand gel dispensers were located around the home and were well stocked. Staff had received training in IPC.

Relatives were keen to tell us how they thought the home was kept clean and well maintained. Comments included, “The home is lovely and clean with no smells. [Name’s] room is clean” and “There are no smells and it’s clean and well presented. It’s decorated lovely."

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People’s medicines were managed safely. A relative told us, “[Name] is on medicines and painkillers and she gets them as she should.”

The clinic room where medicines were stored, was well organised.

Staff responsible for the management of medicines had completed the required training and their competency was routinely assessed. One member of staff confirmed, “I have completed my medicines training and have regular competency checks.”

For people who required PRN medicines (as and when required medicines) PRN protocols were in place and contained appropriate guidance for staff on when and how to use them appropriately.

Both weekly and monthly medicine audits were carried out to ensure medicines and treatments were safe and met people’s needs.