Inspection on 05/01/06 for Hilton Rose

This inspection was carried out on 5th January 2006.

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 29/10/05

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 Mrs Mandy Beck Announced Inspection 5th January 2006 09:30 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 Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 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.V265243.R01.S.doc Version 5.1 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.V265243.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th October 2005 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 being their own furniture and personal belongings with them when they come to live in the home. The home has two floors and can be accessed via the passenger lift or the stairs. There are no restrictions on visiting times and visitors are made welcome in the communal areas of the home or the service users own rooms. There are three lounges, one of which is on the first floor. Meals are usually served in the dining room/conservatory. It is also used for social and leisure activities. The dining room/conservatory overlooks the home’s garden and the rear car park. The premises are sited adjacent to the Arboretum and Walsall town centre shops, libraries and art gallery. The staff group are experienced and provide a friendly, sociable environment for both service users and their families. Most of the staff have National Vocational Qualifications and are working towards level 3. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection it began at 0930 and was concluded at 1500hrs. The purpose of the inspection was to assess the homes progress in meeting some of the requirements from previous inspections. A tour of the building was carried out, relevant files were examined and discussions with the manager, staff and some relatives and service users were held. Information was also used from the pre inspection questionnaire and 8 comment cards were received from service users. The inspector would like to thank all of the staff for their help and hospitality during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Planned programmes need to be produced for the refurbishment and re decoration of the home. Work has begun in one half of the home but the other half is now looking worn and in need of redecoration. Some of the carpets within the home are dirty and stained and in some places are worn out. They should be replaced to improve the appearance of the home and to reduce the risk to service users of tripping over worn areas. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 6 The home works well including service users in all aspects of their health and well being but now it needs to develop the care planning process so that the care being given reflects the care that is written in each individual service users plan. The home needs expand upon the information contained within its complaints and vulnerable adults policy to include relevant information about the Protection Of Vulnerable Adults (POVA) referrals and management of complaints that includes timescales and stages of the complaints process. Not all of the staff working at the home had CRB checks completed at the time of the inspection; no member of staff should be employed before these checks have been satisfactorily completed. An immediate requirement was issued to ensure that this practice does not continue and service users are safeguarded from abuse. All staff must have an appropriate POVA/CRB disclosure. The manager must take steps to rectify this situation immediately. 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.V265243.R01.S.doc Version 5.1 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.V265243.R01.S.doc Version 5.1 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): 1,2,3 Each service user has a service user guide and a service user plan based upon an assessment being completed prior to their admission to the home, this ensures that no one moves into the home without the knowledge that their needs can be met. EVIDENCE: The statement of purpose has been updated since the last inspection and now meets the minimum standards. Each service user has a copy of their terms and conditions within their rooms and they are signed and dated, this was an outstanding requirement from the previous inspection. The home manager visits each prospective service user at home so that an assessment of needs can be completed and also ensure that the home can meet the needs of that person. It was observed that all of the files examined during the inspection had Single Assessment Process information and a detailed assessment completed by the care manager prior to admission that outlines the type of care each individual service user requires. This helps to maintain the continuity of care for the service users. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 9 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): 7,8,10 Service users health, personal and social care needs are generally met and they are treated with respect and dignity at all times but individual needs are not set out in a plan of care this makes it difficult to identify the type of care each individual service user requires. EVIDENCE: Each service user has an individual service user plan however the plan does not detail the type of individual care needed to meet each service users needs. The home needs to develop its care planning system to reflect the collective knowledge that all staff have about the needs of the service users. It is obvious whilst talking to staff that they understand and know how to deliver care to all of the service users at the home but this knowledge has not been transferred into a written care plan for them. The care staff review care delivery on a monthly basis and always with the involvement of the service user who signs the review sheet which helps to demonstrate their involvement in the process and ensures that service users are happy with the service they are provided with. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 10 There is adequate risk assessment and screening in place for monitoring pressure sores, continence, moving and handling and falls but the home needs to develop risk management plans to indicate how these potential risks can be managed or minimised. The home currently has no nutritional screening tool but they do regularly weigh service users and monitor changes and take appropriate action to maintain service users well being. Every service user has access to specialist medical, nursing, dental, chiropody and optical services should they require them. Service users are treated with respect and courtesy. Service users spoken to during the inspection stated that “the staff are golden they help you with anything” “Staff are approachable and make us feel like part of the “family””. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 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): 13,14 Service users are encouraged to maintain contact with their families and friends and enjoy social activities. EVIDENCE: Service users are encouraged to maintain contact with their families and friends, the home has a flexible visiting policy and welcomes visitors. Service users can chose where they receive guests, they can use the privacy of their own rooms or any one of the communal rooms within the home. The home provides information and contact details for services such as, advocates, who would be able to act in service users interests if required. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 12 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 users can be assured that their complaints will be listened to and acted upon but the home needs to further develop its policies to ensure that service users will be protected from abuse. EVIDENCE: The home has not received any formal complaints during the last twelve months. Comments from service users included “if ever we are not happy with something (which is rare) we always speak to staff on duty and it is resolved at once”. This is positive and service users can be confident that all their concerns will be acted upon. Every service user has a copy of the complaints policy contained within their service user file, which is stored in their bedrooms. The current complaints policy does not include all of the requirements of the national minimum standards and needs further development. It does not assure service users that their complaint will be responded to within a given timescale or who will deal with it. The home does not have a complaints log and therefore no record of complaints or of any action taken to resolve them. The homes protection of vulnerable adults policy needs to be reviewed and should include robust procedures that ensure the safety and protection of service users. It does not include information about Protection of Vulnerable Adults (POVA) referrals at present. Staff at the home also need to undertake training to increase their knowledge and understanding of abuse so that service users can feel safe and protected. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 13 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): 26 The home was generally clean and tidy, policies are in place to control the spread of infection. EVIDENCE: Generally the home was clean and tidy, the decoration and carpets are now looking tired and a planned programme of refurbishment should be formulated. Since the last inspection appropriate locks have been fitted to the bathrooms and toilets so that service users can be assured of privacy when using them. One of the toilets on the ground floor has a new lock fitted unfortunately the door does not close because it gets jammed in the frame this compromises service users privacy and was brought to the managers attention during the inspection. Floor tiles are loose in the shower room on the first floor and in toilet number four on the ground floor, presenting a trip hazard to service users. Radiator cabinets have been fitted to all radiators to reduce the risk of burns or injury, however not all of them were securely fixed to the wall and this needs to be addressed. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 14 The sluice is kept locked and all cleaning materials are stored safely and appropriate policies are in place for dealing with spillages and provision of protective clothing. The laundry is situated on the first floor and washing machines have specified programmes to ensure that disinfection standards are met. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 15 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): 27,28,29,30 The home does not safeguard service users by its current recruitment policy and practice. Current staff at the home have completed appropriate training to ensure that service users are in safe hands at all time. EVIDENCE: The home benefits from a well established staff group many of the staff have worked there for more than five years. The home employs domestic staff who work from 9.00 to 12.00 on a daily basis. Kitchen staff work from 7.30 am every day until 1.30pm. Care staff are expected to provide tea and supper for the service users. On the day of the inspection the home was staffed adequately with 3 care staff both morning and afternoon shifts, the home manager is available in addition to these numbers. Staff felt that they were well supported and enjoyed working at the home, it was clear that the team work well together and had a positive relationship with each other and all of the service users within the home. Most of the care staff have now completed the NVQ level 2 and are now working towards their level 3. The home has not recruited any new staff for over twelve months, staff files for the most recent employees were perused and found to be incomplete. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 16 The home had not completed the appropriate checks with POVA/CRB disclosures before the staff had commenced employment in 2004, these checks had still not been completed at the time of the inspection. An immediate requirement was issued for this practice to cease and for all existing staff to have a CRB disclosures. In addition to this there were no references in two of the staff files seen. Service users cannot be assured that staff are recruited in a manner that safeguards their best interests and the manager must take steps to improve this practice. Staff do receive mandatory training which includes, fire safety, moving and handling, first aid and safe handling of medication, it was recommended that the present system of recorded training be revised, consideration should be given to the development of a training matrix which would readily indicate when staff training is due. This would ensure that all staff receive the required training when they need it. Most of the staff at the home now require mandatory training updates to ensure that they continue to care on the principles of best practice. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 17 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): 31,33,35,38 The home manager takes active steps to seek service user views to ensure that the home is run in their best interests. Generally the health, safety and welfare of service users is promoted. EVIDENCE: The manager has completed the NVQ level 4 in management and care, she also receives regular supervision from the registered providers. In an attempt to ensure the home is run in the best interests of service users regular audits are completed, service users, staff and relatives are asked to complete questionnaires about the home and the results are published and made available for all service users to read. All comments and suggestions are acted upon. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 18 Generally safe working practices are adhered to and the home is in sound working order with all equipment being regularly tested and repaired as necessary. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 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 OP9 Regulation 13 Requirement The registered manager must: Produce appropriate policy and procedures for the management of controlled medication (Previous timescale 30/12/05 not met) The registered manager must: Replace the carpet in the porch. Implement a programme for regularly clearing away the debris at the front and rear of the premises. Develop a programme for the refurbishment and redecoration of the premises. ( previous timescale 30/12/05 not met) The registered manager must: Ensure that each service user has an individual care plan which details all aspects of health, personal and social care needs Timescale for action 01/04/06 2 OP19 23 30/04/06 3 OP7 15 30/04/06 Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 21 4 OP8 15 The registered manager must: Ensure that a nutritional screening tool is introduced for all service users. The registered manager must: Update the complaints policy to ensure that service users feel confident their complaints will be dealt with effectively and within an acceptable time frame. Provide each service user with the updated policy. 30/04/06 5 OP16 22 01/03/06 6 OP18 13(6), Introduce a complaints log The registered manager must: 01/06/06 7 OP19 develop written policies to ensure that service users are protected from abuse and that robust procedures for responding to suspicion or evidence of abuse or neglect are in place. These policies must be in line with local adult protection guidelines and the Department of Health’s guidance “No Secrets”, and develop strategies to enable staff to undertake training in adult abuse awareness. 23,13,(4)( The registered provider and 01/04/06 a) registered manager must: Develop a planned programme of redecoration and refurbishment that includes the following Replace the carpet in the hallway it is worn and threadbare in places. The extractor fan in the sluice needs to be repaired to ensure adequate ventilation. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 22 The sluice needs to be thoroughly cleaned and waste products removed The hinge needs to be repaired on the toilet door (toilet 1) to ensure the door closes properly All radiator covers need to be securely fixed to the walls. The offensive odour in room 19 needs to be eradicated Loose tiles in the shower room need to be made safe. Window covering should be provided to toilet 3 (upstairs) Loose tiles on the floor of toilet 4 (ground floor) need to be made safe. The carpet in the staff office needs to be cleaned to remove the stains. The registered manager must not confirm new staff into post until satisfactory checks have been completed (POVA/CRB) All existing staff must have CRB disclosures. No member of staff shall be employed without two written references being available for them The registered manager must ensure that all staff receive appropriate training to ensure that service users are safeguarded from unsafe practices 8 OP29 19(1),(b) 19(4),(b) 05/01/06 9 OP38OP30 18(c) (i) 01/05/06 Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 23 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 OP30 OP19 Good Practice Recommendations The manager should consider the introduction of a training matrix that readily identifies when staff are due for updates in mandatory training. The manager should consider the introduction of a maintenance log book to ensure that all minor repairs and defects are addressed and a record is available of works requested. Hilton Rose DS0000020812.V265243.R01.S.doc Version 5.1 Page 24 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.V265243.R01.S.doc Version 5.1 Page 25 - 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!