Inspection on 05/01/07 for Hilton Rose

This inspection was carried out on 5th January 2007.

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 05/01/06

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 Mandy Beck Key Unannounced Inspection 5th January 2007 09:00 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.V324348.R01.S.doc Version 5.2 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.V324348.R01.S.doc Version 5.2 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.V324348.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 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 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. The home currently charges £327.15 per week for residency. There are additional charges for hairdressing, chiropody, newspapers, toiletries, outings and day centres. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of this service completed by one inspector from the Commission for Social Care Inspection (CSCI). The inspection took place over one day and involved talking with the person in charge, service users and staff. Service users files were also examined as part of the case tracking process. This process means looking at assessments, care planning and risk management to make sure that service user needs are being met. Staff files were seen, to ensure that the home continues to recruit people in a safe manner. In addition to this a tour of the premises was undertaken. The information and judgments made in this report have been done using all available evidence including a pre inspection questionnaire completed by the manager and information from service user surveys. The inspector would like to thank all of the staff and service users for their hospitality and assistance throughout the inspection. What the service does well: The home is friendly and all of the staff clearly have a good relationship with service users. All service users can be assured that their needs will be assessed and that they will only be admitted to the home if the manager feels confident that they can meet those needs. Service users stated that they were happy with the care and attention they receive from staff throughout the day and night. “if ever you need anything you just ask, they do the best they can”. Visiting professionals stated that “the team here are competent and very caring”. Mealtimes are relaxing and unhurried, all of the service users spoken to said that they enjoyed the food here and that there was always plenty for them to eat. The staff group at the home is very stable and they have worked hard to complete their National Vocational Qualifications (NVQ) level 2 and level 3 in some instances. This means that they are equipped with knowledge and skills to complete their duties. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 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.V324348.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users who move into the home can be assured that their needs will be assessed in full prior to admission. EVIDENCE: All of the service users files that were seen as part of the case tracking process, contained an assessment of need, this had been completed by the manager prior to their admission and updated as needs changed. Some of the service users had information supplied to the home in the form of the Single Assessment Process (SAP) from the local teaching Primary Care Trust (PCT), that also outlined the care needs of service users. Once these assessments are completed they help for the basis for all care planning within the home. This home does not provide nursing or intermediate care. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that their needs will be met. Medication practices must be improved to safeguard service users. All service users are treated with respect and dignity. EVIDENCE: Three service user files were seen as part of the case tracking process. It was pleasing to see that all of the staff have worked hard to introduce new paper work and risk assessments for service users. Each service user has care plans that are based upon the needs highlighted in their assessment. There are also risk assessments that determine their level of risk for developing pressure sores, falls, moving and handling. It is positive that each service user is now screened for their risk of malnutrition and that this is kept under review, this means that service users who are at risk will be identified and appropriate action will be taken. Each of these risk assessments has a management/risk reduction plan. There was evidence that staff have attempted to review care plans and risk assessments but this needs to be done and documented at least on a monthly Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 10 basis. The manager must also be able to show that service users have been involved in this process. It was also noted that two service users have bed rails on their beds to keep them safe during the night. The person in charge assured the inspector that risk assessments for bed rails are usually in place but she was unable to locate on the day of inspection. When checking the bed rails for one service user it was noted that there were no protective covers available for them, this was bought to the attention of the person in charge who said that she would rectify this. It is evident that service users receive medical attention when they need it and throughout the inspection Doctors and community nurses were seen to be visiting. One Doctor commented “the staff here are very competent and I have every confidence in them”. Service users said “the staff will always try and get the doctor if we feel poorly”. The home also receives visits from dentists and chiropodists; however there may be a charge for this service. Medication practices within the home require improvement. One area of serious concern was highlighted, the controlled drugs storage cupboard was inadequate and must be replaced and secured to the wall to comply with legislation. On this occasion it was free standing on the office desk with the key in the door. This was bought to the attention of the person in charge and an immediate requirement was issued asking for the home to respond to the CSCI within 48 hours with their proposals to rectify this situation. The medication fridge needs a minimum/maximum thermometer to enable staff to record the temperature so that they can be sure medication is being stored at the recommended temperatures. The person in charge at the time of the inspection did state that a thermometer is on order and they are awaiting delivery. The temperature of the medication storage room (office) must also be recorded on daily basis for the same reason. The medication policy has now been updated to include the administration of controlled drugs it still needs to be reviewed to include to administration of homely remedies. There were other shortfalls identified during the inspection, so in order to assess this standard in more detail a referral to the CSCI specialist pharmacy inspector has been made, and they will visit the home at a later date. All of the service users who were spoken to during the inspection were very positive about the way that staff treat them and had only positive things to say about them: “they try the best they can, they are very good”, “ they make me very happy here”, “we laugh and we joke, I give them a lot to put up with”. It was clear on the day of inspection the staff team have good relationship with the service users and were seen to be addressing them politely and sensitively through out the day. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to take part in life at the home, visitors are encouraged and meals are provided in sufficient quantity to meet service users needs. EVIDENCE: The home provides activities for service users to take part in if they choose to do so. These include bingo, outings and out side entertainers. Staff do have limited time to spend on activity with service users because they are expected to complete other tasks around the home. Consideration should be given to the recruitment of an activity coordinator so that service users can be sure that they have dedicated time each week for activity. The home encourages visitors and on the day of inspection there was a steady stream of them. One relative commented “do you know they are so good here, they work like Trojans”. Advocacy details are displayed in the corridor by the front door, this means that service users will have the opportunity to contact an advocate if they want someone impartial to act in their best interests. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 12 Meals are relaxed and unhurried, service users are assisted discreetly and tables were set to enable service users to eat their meals independently. The home operates a four weekly menu giving service users a choice of two meals each day for dinner. The home also provides breakfast, tea and supper. Tea and coffee is available freely and there is the opportunity for service users to have snacks throughout the day. It was pleasing to see that the Kitchen staff have a good relationship with service users and understood their dietary requirements. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be assured that all concerns and complaints will be listened to and acted upon. There must be an improvement in policy and staff training in order for service users to be fully protected from abuse. EVIDENCE: The manager has reviewed the complaints policy since the last inspection; it now details timescales for responding to complaints and contained all required information. The home has received no complaints for over twelve months. It has received many compliments on the care that it provides for service users though; one comment stated, “Wonderful staff, lovely place, as much like home as one could hope for. The staff are brilliant at coping with mom, they clearly care for her”. There is a policy available for staff to access about vulnerable adults, and the Protection of Vulnerable Adults (PoVA) register, in addition to this the home also has a whistleblowing policy that enables staff to raise concerning issues in confidence. The PoVA policy could be further developed to include specific details of the local authority’s protocols regarding Adult Protection and an easy read flow chart for staff to follow. None of the staff have received training in Adult Protection and recognising signs of abuse, this is an outstanding requirement from the previous inspection and must be addressed to ensure that service users are protected at all times by staff who have the knowledge and skill to recognise and deal with abuse. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is no longer well maintained and there are many areas of the home that need attention to make sure that they are safe for service users. EVIDENCE: The home has made some improvements to the environment since that last inspection, the offices and the porch have both had new flooring replacing the stained and worn out carpets. Two bedrooms have also been redecorated for service users. However there are many areas of the home that require attention to ensure that it is safe for service users. A tour of the premises revealed that most of the bathroom and toilets require replacement flooring, at present the flooring is split and has risen, the risk to service users is twofold, it poses a trip hazard and a increased risk of cross infection. Wallpaper is peeling in places and some rooms are in need of redecoration. One lounge upstairs requires deep cleaning the windows were Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 15 dirty, the curtains had come off the rail and furniture is worn. Radiator cabinets were not secured to the wall in all cases. The temperature of hot water available for service users needs to be checked, in one bathroom the inspector was unable to hold a hand under the hot water because it was too hot, this was also the case in two service users bedrooms, this requires attention as this poses a scalding risk to service users. The laundry is inadequate and does not protect service users again the risks of infection, the walls are not readily cleanable and the flooring is not impermeable, there was evidence of a flood in the laundry that has resulted in some of the flooring be taken up and leaving a small area of floorboards exposed. The tumble dryer was in use during this time and the heat and condensation generated from this made the room humid and damp, there is inadequate ventilation. There must also be a laundry cleaning schedule displayed in the laundry that all staff can follow. Red bags should be available for the laundering of heavily soiled and infected clothing. The sluice requires a deep clean and the removal of extraneous items, as with the toilets and bathrooms the flooring in the sluice also requires attention to ensure that it is also impermeable. In order to further safeguard service users the sluice must be locked at all times. The kitchen has been recently inspected by the Environmental Health Department who made several requirements regarding the safe storage of food. It was pleasing to see that some of these requirements had been addressed. Outside the gardens look neglected and in need of attention, there was rubbish and debris waiting to be moved. Chairs were lying on their sides and some benches appeared neglected and in need of revarnishing. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are cared for by a staff group that is dedicated and experienced. Generally there are sufficient staff on duty to meet service users needs. Staff are trained and competent to do their jobs. EVIDENCE: The home generally has sufficient staff on duty to meet service users needs. There are usually three carers on duty both morning and evening and two carers during the night. The manager’s hours are supernumery this means that she is free to manage the home and deal with any issues that arise. The care staff are supported by domestic and kitchen staff who keep the home clean and ensure that service users are well fed. At present the home has no help with laundry services, care staff are expected to do this as part of their role, what this means is that care staff have reduced contact with service users as they attend to the laundry. The home has high levels of staff with both NVQ level 2 and 3 and all staff should be congratulated upon their hard work in completing this. The manager has made good progress with the staff files, a total of three were seen on this occasion and generally they contained all the required information. It was pleasing to note that staff now have appropriate PoVA and CRB disclosures in place, this was a requirement from the last inspection. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 17 The home has a very stable staff group and as a result the home has not recruited any new workers since the last inspection. The induction records of existing staff were seen in order to assess the process and the content of the programme, if new staff are recruited in future the induction programme will need to be updated to ensure that is meets the Skills for Care Induction Standards. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home cannot be sure that it protects the health, welfare and safety of service users. EVIDENCE: The manager of the home is Helen Evans and she has the required qualification and skills to run the home and manage the staff. The manager has worked well with staff to improve record keeping for service users and has made good progress in meeting some of the requirements from the previous inspection report. The home does have a quality assurance system that attempts to gain the views of service users and their relatives, this is done on an annual basis and is currently due again. What needs to happen now to make sure that this Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 19 process moves forward is for the manager to publish the results of these surveys and any required actions to meet the points raised. It would also be of benefit if the manager considered expanding her audits to include an environmental audit and one for medication to ensure that any shortfalls can be identified and acted upon. The home keeps money safe for two service users, at present there are insufficient safeguards in place to protect service users and staff. Records of all transactions are recorded and some receipts kept, but there are no receipts when staff hand over service users money to relatives. The home must be able to demonstrate that when this happens it is the service users wish that staff do this. Wherever possible the service user must sign to indicate that they have received their money and that there are two signatures for all transactions. Safe working practices within the home must be improved to ensure the welfare, health and safety of service users is protected. A letter expressing serious concerns has been issued to the registered provider in respect of this. Safety certificates were spot checked and found to be missing. There were no certificates to show that the Gas Landlords Certificate was up to date, and no electrical installation certificate (5yr), these documents must be available for inspection at all times. More concerning was the lack of information on the fire safety systems within the home. The fire detection and alarm system inspection was deemed “unsatisfactory” in February 2005 but there is no evidence to suggest that this has been actioned and the system made safe. Staff have not received any fire safety training since 2005 this must be addressed immediately as all staff must receive training at least once a year minimum. Staff do have fire drills but this must include all night staff. Mandatory staff training has gaps, it is acknowledged that some staff are currently undertaking infection control training and health and safety training but much more training needs to take place to ensure that staff are practicing within current best practice guidance. The staff group must have training in moving and handling and food hygiene. All staff must have mandatory training on an annual basis to make sure that their skills and knowledge are kept up to date. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 X X X X X 2 1 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 1 Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 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 OP7 Regulation 17(1)(a) sch 3 13(4) (c ) Requirement The registered manager must ensure that all service user plans contain a recent photograph of the service user The registered manager must ensure that all service users have a risk assessment for the use of bed rails. Where service users have bed rails, protective covering (bumpers) should be provided. 3 OP7 15 All risk assessments must be reviewed at least on a monthly basis for each service user. All care plans must be reviewed at least on a monthly basis. 4 OP9 13(2) A ‘Homely Remedy’ procedure must be available that has been agreed by the GP’s. Controlled Drug Storage must meet The Misuse of Drugs (Safe Custody) Requirements 1973. – immediate requirement 01/04/07 01/02/07 Timescale for action 01/04/07 2 OP7 01/02/07 Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 22 5 OP9 13(2) The registered provider must obtain a minimum/maximum thermometer for the drugs fridge. The registered persons’ must ensure that medication is stored at the required temperature in all areas. Room temperature must not be above 25oC and refrigerated storage must be 2-8 oC. 01/02/07 6 7 OP9 OP18 13(2) 13(6), This must be recorded daily. The medication trolley must be secured to the wall when not in use. The registered manager must: 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. (previous timescale of 01/06/06 part met) 01/02/07 01/04/07 8 OP18 13(6) The registered persons’ must ensure that Walsall Councils’ adult protection procedures are easily accessible to staff. These must be complimented by a quick reference flow chart to allow staff access to names and telephone numbers for contacts in case there is an incident or allegation of abuse. The registered manager must: 01/04/07 9 OP19 23 01/02/07 Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 23 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) 10 OP19 23,13,(4)( The registered provider and a) registered manager must: 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. The sluice needs to be thoroughly cleaned and waste products removed All radiator covers need to be securely fixed to the walls. Loose tiles in the shower room need to be made safe. (previous timescale of 01/04/06 not met) 11 OP19 23 The registered provider must provide a lock for the sluice and make sure that the sluice is kept locked at all times. The registered provider must seek professional advice about the safety of the hoist in the upstairs bathroom. The registered provider must ensure that hot water is kept at required temperatures and does not pose a scalding risk. The flow and return of water Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 24 01/04/07 01/02/07 12 OP22 23 01/03/07 13 OP25 23 01/02/07 must also be recorded. The registered provider must address the inadequate water temperatures and provide a risk assessment to demonstrate how service users are not being placed at risk. The registered provider must provide adequate ventilation in the laundry room. The walls must be washable The flooring needs to be repaired or replaced to ensure that it is impermeable. There must be a laundry cleaning schedule on display in the laundry to guide staff. Hand wash signs in all bathrooms , toilets and high risk areas an example being the laundry must be available That red disposable bags are purchased to put straight into the washing machine to prevent staff having to touch heavily soiled or infected washing. All loose and raised flooring in bathrooms and toilets must be made even and impermeable to reduce the risk of cross infection and trip hazard. All foods are date labelled when opened. That fridge temperatures are taken and recorded daily and available for inspection That all mops used in the home are colour coded and there must Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 25 14 OP26 13(3) 01/04/07 be a programme for their daily cleaning. 15 OP30 18(2,3,4) The registered manager must 01/04/07 review the induction programme to ensure that it meets the Skills for Care Standards for all new employees. The current quality assurance 01/04/07 system must be expanded to include regular medication and environmental audits, with action plans and timescales produced to address issues arising. The registered provider must also undertake unannounced monthly visits to the home as required by regulation 26 The registered manager must ensure that two signatures are recorded for all transactions when dealing with service users monies, one of which should be the service user. Receipts of all transactions must be given/obtain, for instance when handing over service users monies to relatives. The registered manager must ensure that all staff have appropriate training to ensure that service users are safeguarded from unsafe practices. This must include Moving and handling First aid Food hygiene Health and safety (previous timescale of 01/05/06 not met) 19 OP38 23 (5) The registered provider must ensure that the requirements DS0000020812.V324348.R01.S.doc 16 OP33 24,26 17 OP35 17(2) sch 4 01/04/07 18 OP38 18(c) (i) 01/04/07 01/04/07 Page 26 Hilton Rose Version 5.2 from the Environmental Health Department are actioned. 20 OP38 23 (4) The registered provider must forward to the Commission for Social Care Inspection written confirmation from the Fire Service that fire systems within the home are safe and in working order. All staff must receive fire safety training at least once yearly. All staff must participate in fire drills. Records of fire drills must be made to detail the date and each staff members name and their signature obtained to verify their attendance. All automatic door closures must be in working order 21 OP38 23 (1) (2) The registered provider must forward to the Commission for Social Care Inspection written confirmation that they are in receipt of a current Gas landlords safety certificate Electrical installation certificate (5year). These records must be available for inspection. 01/02/07 01/04/07 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 Good Practice Recommendations Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 27 1 2 OP12 OP19 3 4 OP26 OP30 It is recommended that the registered provider consider the employment of an activity coordinator for the home. 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. It is recommended that the home obtain a copy of the Department of Health publication “infection control guidance for care homes” June 2006. The manager should consider the introduction of a training matrix that readily identifies when staff are due for updates in mandatory training. Hilton Rose DS0000020812.V324348.R01.S.doc Version 5.2 Page 28 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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