Inspection on 29/10/05 for Hilton Rose

This inspection was carried out on 29th October 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

Hilton Rose 29/05/07

Hilton Rose 05/01/07

Hilton Rose 05/01/06

Hilton Rose 21/10/04

Hilton Rose 24/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hilton Rose 30 Broadway North Walsall West Midlands WS1 2AJ Lead Inspector Ms Linda Elsaleh Unannounced Inspection 29/10/05 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 Hilton Rose DS0000020812.V260298.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. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hilton Rose Address 30 Broadway North Walsall West Midlands WS1 2AJ 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) 01922 622778 01922 645960 Mr John Rose Mr Hilton Thomas Smith Mrs Helen Evans Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21/10/04 Brief Description of the Service: Hilton Rose retirement home has a homely atmosphere and cares for up to twenty-three retired ladies and gentlemen over the age of 65 years. There are two double bedrooms and nineteen single rooms and all are fitted with wash hand basins. Residents may bring their own furniture and personal belongings with them. The home has two floors with a lift to the first floor. There are no restrictions on visiting times and visitors are made welcome in the communal areas of the home or in service users own rooms. There are three lounges, one of which is on the first floor. Meals are usual served in the dining room/conservatory. It is also used for social and leisure activities. The dining room/conservatory overlooks the flower borders and the rear car park. The premises are sited adjacent to the Arboretum and close to the Walsall town centre shops and library etc. The staff group are well experienced and provide a friendly, sociable environment for service users and their families. A number have NVQ qualifications or are working towards NVQ level 3. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out during the morning of Saturday 29th October 2005. The purpose of the visit was to assess the progress made by the home in meeting some of the requirements made at previous inspections and its performance against some of the selected key standards from the National Minimum Standards for Care Homes for Older People. A tour of the building was carried out, relevant records examined and discussions took place with the registered manager, staff and some service users. The atmosphere within the home was relaxed. Comments made by service users were generally positive about the care being provided. Where applicable, the manager was informed of comments that required attention. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose must include details of all the information required by Regulation 4, Schedule 1 of the Care Homes Regulations 2001 and ensure contracts are signed and dated by all relevant persons. The home’s policy and procedures for the handling of medication must be revised and implemented. Planned programmes need to be produced for the maintenance, refurbishment and re-decoration of the premises. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 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. Hilton Rose DS0000020812.V260298.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 Hilton Rose DS0000020812.V260298.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): 1&2 Service users are provided with information about the home in the form of a Statement of Purpose and Service User Guide. This information needs to be revised to ensure service users are provided with all the necessary information to enable them to make an informed choice about where they live. The contracts agreed by the home and service user must be signed and dated. EVIDENCE: The home has a Statement of Purpose. It does not contain all the information detailed in Regulation 4 Schedule 1 of the Care Home Regulations 2001. Each service user is provided with their personal copy of the Service User Guide. The contact details for the Commission for Social Care Inspection (formerly National Care Standards Commission) needs updating. Both documents are provided in large capital print. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 9 Each service user is issued with a copy of their contract/statement of terms and conditions and a copy is also kept with the individual records. A sample of the contracts examined had not been signed and dated by the management and/or service user. Hilton Rose DS0000020812.V260298.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): 9 The home’s management of service users’ medication is generally satisfactory. However, it must develop its policy and procedure in respect of controlled medication. Details of service users who self-medicate must be included in their care plan. EVIDENCE: The majority of service users’ medication is managed, on their behalf, by senior staff. The home uses the Boots Monitored dosage system. Satisfactory arrangements are made for the safe storage of this medication. The administration of medication was inspected. Medication Administration Record sheets (MARS) were clearly printed with relevant details and prescription instructions. It is the home’s policy and practice for all medication to be administered by two members of staff, one of who must be a senior. A small medication refrigerator is available. The home’s policy and procedure does not comply fully with the guidance on the management of controlled medication issued by the Royal Pharmaceutical Society of Great Britain. This was discussed with the manager and a senior staff member. Two service users manage some of their own medication. These details must be included in their individual care plan. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 11 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 & 15 Service users are supported by the home to maintain their individual lifestyles. They are encouraged to participate in individual and social activities. Staff will assist service users in making transport arrangements. The home provides service users with suitable mealtime arrangements. There is a varied menu and satisfactory records are kept. EVIDENCE: The inspector arrived as some service users were finishing their breakfast in the dining room/conservatory. The room is light, bright and spacious and is used for other activities and social occasions. It overlooks the outdoor seating area, flowerbeds and rear car park. Staff were attentive to the needs of the service users. The main meal is serviced at lunchtime. The day’s menu is displayed on the board in the dining room near the door. Service users are able to request alternative meals if they wish. Drinks and refreshments are available throughout the day. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 12 A fulltime cook is employed by the home. Unfortunately, on the day of the inspection she was unwell. However, suitable arrangements had been made to cover in her absence. The kitchen was generally in good order, clean and hygienic. All equipment is in working order and regularly serviced. There are adequate stocks of dry, fresh and frozen food. Appropriate records are kept of food, refrigerator and freezer temperatures. Information is available of individual preferences and any special dietary needs of service users. The service users expressed satisfaction with the meals provided. The care staff organise a range of activities for service users that meet with their individual interests and abilities. A programme of activities is displayed on the notice board in the dining room. Relatives are encouraged and invited to join in with events and outings. During the summer months barbecues and other outdoor events are arranged. One service user spoke to the inspector about regular trips made to local social events/clubs and transport arrangements to enable them to access these. Service users were observed following individual hobbies, such as needlecraft and art and others were relaxing watching television. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 13 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): 17 The home has suitable procedures for ensuring service users rights to privacy and confidentially is observed. EVIDENCE: Service users reported that their right to privacy is respected and staff provide them with appropriate support with their personal care where required. Staff address service users with their preferred name/title and observe their right to confidentiality. There are suitable and secure arrangements for keeping service users information. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 14 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, 20, 21, 23, 24 & 25 Service users have access to arrange of communal rooms that are adequately furnished and a choice of bathing facilities. Seating in the dining room must have suitable covering that maintains service users dignity. More privacy must be provided for service users when using toilet and bathing facilities. Items for use in showers/bathrooms must be stored appropriately. Equipment provided in service users bedrooms must be fitted for comfort as well as safety. To maintain and improve standards the home needs to produce planned programmes for the maintenance, refurbishment and redecoration of the premises. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 15 EVIDENCE: The home is located opposite to the Walsall Arboretum and close to the town centre. It is a large converted property that has been extended to improve the provision to service users. Service users have access to a pleasant garden and suitable seating is available. There are good off-road parking facilities. The inspector was informed the stonework at the front of the premises has been cleaned and painted during the last 12 months. The accumulation of debris, such as leaves and litter, in this area indicates that it is not cleared on a regular basis. The carpet in the small porch area where some service users sit is frayed and loose. This needs to be replaced. The manager is advised to give consideration to developing a long-term programme for the maintenance of the property, given its age. A few service users take breakfast in their rooms and others return to their rooms after taking breakfast in the dining room. Service users often use the dining room/conservatory to wait for their transport to arrive and/or to receive visitors. However, they may receive visitors in their own rooms, if they choose. A plastic covering protects some dining chairs. The manager needs to replace this with a more suitable covering that protects service users dignity. The home has three lounges and each has an atmosphere of its own. Most service users were comfortable in the main lounge and were watching television. In the second lounge service users were sitting chatting and one service user was reading a newspaper in the third. There is adequate seating in all lounges and service users commented that the upright winged chairs provided were comfortable. There are adequate bathing facilities. Grab rails and other aids are fitted, where necessary, and the home has taken delivery of a new bath hoist. Arrangements have been made for this to be professionally fitted. Suitable storage must be provided for the cleaning materials seen on the shower room floor and the toiletries placed on the shelf of a nearby radiator. Some bathrooms and toilets do not have suitable door locks fitted. This is an outstanding requirement from a previous inspection. The floor covering in one of the bathrooms has lifted, causing a trip hazard. This was brought to the attention of the manager, who stated it would be addressed immediately. The inspector can confirm this work has now been carried out. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 16 The bedrooms are furnished with a mixture of the home’s furniture and those brought in by service users. A risk assessment is made of items brought into the home to ensure they do not present a hazard to service users or others. Some of this furniture is worn and the home needs to produce a programme for refurbishment. Lockable storage space is available for keeping valuables and medication. Bedrooms reflect service users’ individuality. One service user’s bed is fitted with side rails. The home must have suitable bumper cushions fitted for the service user’s safety and comfort. The home re-sited the laundry facilities last year. This now includes an ironing room and shelves for storing washing powder etc. The home has satisfactory heating, lighting and ventilation. Covers have been fitted to radiators in communal areas. The inspector was informed that these have also been fitted, where required, to radiators in service users bedrooms. Hilton Rose DS0000020812.V260298.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): These standards were not assessed at this inspection. EVIDENCE: N/A Hilton Rose DS0000020812.V260298.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): These standards were not assessed at this inspection. EVIDENCE: N/A Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 19 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 2 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 2 2 2 X 3 2 3 X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 20 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 OP1 Regulation 4, Sch 1 Requirement The registered manager must ensure the home’s Statement of Purpose includes all the information required by the Care Homes Regulations 2001. The register manager must ensure service users’ contracts/statement of conditions are signed and dated. The registered manager must: • produce appropriate policy and procedures for the management of controlled medication ensure details of arrangements for service users who self-medicate are included in their care plan 30/12/05 Timescale for action 17/02/06 2 OP2 5 17/02/06 3 OP9 13 30/12/05 • 4 OP19 23 The registered manager must: • replace the carpet in the porch Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 21 • • implement a programme for regularly clearing away the debris at the front of the premises develop a programme for the refurbishment & redecoration of the premises 17/02/06 6 OP20 12, 23 The registered manager must replace the protective covering on dining chairs with a more suitable material. The registered manager must ensure suitable door locks are fitted on bathroom and toilet doors. (Previous date for compliance 31st January 2005) The registered manager must provide suitable storage for cleaning materials & toiletries. The registered person must provide an assessment of the premises and facilities by suitably qualified person, including a qualified occupational therapist. Not assessed at this inspection. The registered manager must provide suitable bumper cushions for bed rails. Ensure a minimum of 50 trained members of care staff NVQ level 2 is achieved by 2005. Not assessed at this inspection. 7 OP21 12 30/12/05 8 OP21 23 30/12/05 9 OP22 16, 23 31/12/05 10 OP24 12,16 30/12/05 11 OP28 18 31/03/05 Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 22 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 Refer to Standard OP19 Good Practice Recommendations The registered manager is advised to give consideration to developing a long-term maintenance programme for the home. Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Hilton Rose DS0000020812.V260298.R01.S.doc Version 5.0 Page 24 - 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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