Random inspection report
Care homes for older people
Name: Address: Aldergrove Manor Nursing Home 280a Penn Road Penn Wolverhampton West Midlands WV4 4AD zero star poor service 14/01/2010 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Ian Henderson Date: 0 7 0 4 2 0 1 0 Information about the care home
Name of care home: Address: Aldergrove Manor Nursing Home 280a Penn Road Penn Wolverhampton West Midlands WV4 4AD 01902621840 01902621841 aldergrovemanor@schealthcare.co.uk www.schealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Southern Cross Healthcare Services Ltd Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 70 Number of places (if applicable): Under 65 Over 65 0 70 0 dementia old age, not falling within any other category physical disability Conditions of registration: 70 0 70 The maximum number of service users who can be accommodated is: 70 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 70, Old age, not falling within any other category (OP) 70, Physical disability (PD) 70 Date of last inspection
Care Homes for Older People 1 4 0 1 2 0 1 0 Page 2 of 8 Brief description of the care home Aldergrove Manor is owned by Southern Cross Healthcare Ltd. It is a purpose built, two storey building, standing in its own grounds and is set back off the main road on one of the main routes into Wolverhampton city centre. It is on a main bus route, close to the city railway system and within easy access to local shops and community facilities. All 70 bedrooms are single with en-suite, some of which have interconnecting doors for couples. There is a passenger lift to enable access between floors. The home consists of a 19 bedded unit for older people with dementia, a 17 bedded unit for younger adults who have physical disabilities and a 34 bedded nursing unit. The door to the unit for people with dementia has a specific door entry system and the door is locked, to help keep people safe. Staff support people from this unit to access other parts of the home. People can obtain information about this service from the homes Statement of Purpose and Service User Guide. The Service User Guide notes the current fees charged by the home as ranging from £449.87 (residential) to £789.36 (nursing) per week depending on care required. The reader is advised to seek information direct from the service. Inspection reports produced by CQC can be obtained direct from the provider or are available on our website at www.cqc.org.uk. Care Homes for Older People Page 3 of 8 What we found:
The reason for the inspection was to assess whether there had been any improvements in the management of medicines within the home since the last inspection on the 14th January 2010. At that inspection we had found continued breaches of the Care Homes Regulation 2001 with respect to the management of medicines. As a consequence a number of medication records and care plans were seized under the provision of the Police and Criminal Evidence Act 1984. In line with the Care Quality Commissions [CQC] enforcement policy the decision was taken to serve a Statutory Requirements Notice in relation to the management of medicines. However due to the technical difficulties within the regional office the serving of the notice was not possible. So the visit on the 7th April was to have a second look at how the home was performing in relation to the management of medicines and decide whether there was any need to take the home down the enforcement pathway again. Of the sample of administration records we looked at during the inspection we found on the whole that the home was recording the receipt of the medicines entering the home well. We found on the whole that the administration records could demonstrate that the people who were using the service were receiving their medicines as prescribed. There was however a discovery that one of the people using the service had not been administered their inhaler. This particular inhaler had an indicator that showed the user how many doses were left before it ran out. The inhaler would have had 124 doses upon opening and the administration records showed that since opening a quantity of 84 doses had been administered. We would have expected therefore that the indicator on the inhaler would be showing that there were 40 doses available for the user. We found that the indicator was showing that there were 90 doses still available indicating that only 34 doses had actually been administered. The manager admitted that the use of inhalers had not been examined during the regularly audits carried out by the home. The inspector felt confident that the use of inhalers would be examined much closer in the future. The only continued issue found with the administration records was that the nursing staff were using the abbreviation E when they had not been able to administer some medication. The abbreviation E signified that the medication concerned had been refused and had been destroyed in line with the homes policies on the disposal of medicines. We found however that the disposal of these refused medicines was not being recorded in the homes disposal register so these medicines remained unaccounted for. We found that the nursing staff and the unit managers had all attended an advanced medication course. We found that all of the nursing staff had undergone an assessment of their competence to administer medicines safely and accurately. We found that the unit managers were in the process of completing the competency assessments on the care staff who administer medicines upstairs. We found that senior carers who were administering medicines have also done a foundation medication course. We found that medicines were being stored at the correct temperatures and the fridges used to store medicines requiring cold storage conditions were being properly monitored. We did not find any medicines that had passed their expiry date at this inspection. We therefore concluded that the home had made sufficient progress for CQC not to progress further down the enforcement pathway. IT was agreed with the lead inspector
Care Homes for Older People Page 4 of 8 for the home that a pharmacist inspector would attend at the next key inspection in order to establish the home ongoing compliance with the management of medicines. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 8 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 9 13 Accurate, complete and up to 13/10/2009 date records must be kept of all medication received, administered, taken out of the home when residents are on leave and when medication is disposed of. This is to ensure that medication can be accounted for and is given as prescribed. 2 9 18 Staff must be suitably 13/10/2009 qualified, experienced and competent to safely administer medication before they administer medication to people who use the service. This is to ensure people receive their medication as prescribed from skilled staff. 3 27 12 Staffing levels for all shifts must be reviewed to take account of peoples needs, dependency and layout of the home. This is to ensure peoples needs are met safely and promptly. 04/03/2010 Care Homes for Older People Page 6 of 8 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 7 of 8 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 8 of 8 - 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!
