This inspection was carried out on 19th May 2009.
CQC found this care home to be providing an Adequate service.
The inspector found there to be outstanding requirements from the previous inspection
report. These are things the inspector asked to be changed, but found they had not done.
The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for older people
Name: Address: Ambleside Residential Home 69 Hatherley Road Cheltenham Glos GL51 6EG one star adequate service 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: Adam Parker Date: 1 9 0 5 2 0 0 9 Information about the care home
Name of care home: Address: Ambleside Residential Home 69 Hatherley Road Cheltenham Glos GL51 6EG 01242522937 01242522937 pepwalsh@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : James Christopher Walsh,Perpetual Walsh care home 18 Number of places (if applicable): Under 65 Over 65 18 old age, not falling within any other category Conditions of registration: 0 The maximum number of service users who can be accommodated is 18. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Ambleside is a large, detached, Victorian house that has been extended and adapted to provide accommodation for older people. It is situated in a residential area of Cheltenham close to a few shops and the bus route into town, which is approximately a mile away. The railway station is within easy reach, together with a number of churches. The accommodation is located on three floors that are all served by a shaft
Care Homes for Older People Page 2 of 12 0 7 0 3 2 0 0 9 Brief description of the care home lift and stairs. All the bedrooms have en-suite facilities, approximately five have a bath or shower. There are three bathrooms two of which have hoists. Ground floor communal facilities include a dining room and two lounges one of which has a piano. The lounge at the rear of the property is an extension of the main building and gives an all round view of the large landscaped garden. A patio area provides a pleasant place for service users to sit in warmer weather. The provider supplies information about the home, including the most recent CQC report to current and prospective residents on request. The fees range from 250.49 pounds per week for local authority funded residents and 610 pounds per week for privately funded residents. Hairdressing, chiropody and any personal items are charged extra. The costs of these services are available as required. Care Homes for Older People Page 3 of 12 What we found:
We visited the home again to inspect arrangements and practices for dealing with medication to make sure that the Statutory Requirement Notice that was served on 21 April 2009 was met so we were checking that there were safe systems in place to make sure of safe administration, safe recording and safe handling of medicines. We looked at some stocks and storage arrangements for medicines and various records about medication. We saw how staff administered some medicines to people living in the home. We spoke to one of the registered providers, the acting manager and three carers. We gave full feedback after the inspection to the registered provider and acting manager about the medication issues we found. We considered that there was not always enough evidence to judge that the issues about the handling of medicines included in the Statutory Requirement Notice had been sufficiently attended to. There were still weaknesses in the arrangements for managing and handling medication that were a risk to people living in the home. We will therefore carry out a further inspection to monitor compliance with the Notice. We will then expect the new manager to have put in place improvements that will mean that people living in the home are not put at risk from poor practices with medication and that the notice is fully complied with. Some requirements made at the last inspection were not fully actioned and still remain in the report. The storage arrangements for medication were changed and offered better security than was seen at the inspections in March 2009. The medicine fridge was broken at the time of the inspection and the manager told us a new one was on order. In the meantime we saw a chiller cabinet was in use but this was not cold enough for keeping medicines that needed fridge storage. We suggested a locked container be placed in the food fridge until the proper medicine fridge was delivered so that the medicine could be kept within the correct temperature range to make sure its full potency was retained. We looked at the arrangements for keeping records about medication received, administered and leaving the home or disposed of (as no longer needed) for each person in the home. The records we looked at for particular people were in place and we saw that these were now held to preserve confidentiality. We were concerned about the accuracy and reliability of some of the records of medicines administered. As a result of their own audit checks the home had reported to us about evidence that staff had signed for administering medication but in fact had not. We also found a few examples of this. As the home were not admitting new people at the moment were not able to check if robust arrangements were in place for recording and checking medication when people first come or return to the home. This was an issue at the previous inspection and included in the Statutory Requirement Notice. We saw some examples of poor practice on medication administration records. Some had sticky labels attached with handwritten notes or even second labels from another pharmacy. Some handwritten notes were not signed, dated or with a second signature as a check that the information was correct. Some charts still included medicines that were not in use. This could be confusing to staff. The times for administration printed on the
Care Homes for Older People Page 4 of 12 charts still did not reflect what happened in the home. We again pointed out as at the last inspection that the times printed on many medicine charts (8am, 12 noon, 5pm and 8pm) do not always provide the necessary four-hour interval between doses for medicines containing paracetamol. This needs changing by liaison with the pharmacy that provide printed medicine charts each month. From the records we looked at no person appeared to have been given paracetamol doses at the wrong intervals but having times printed like this could wrongly lead staff to believe these are safe intervals and so put people living in the home at risk. The registered provider told us she had recently spoken to the pharmacist about this when they visited the home. We spoke to the pharmacy about this again during the course of the inspection. We checked to make sure that pain relieving medicines administered by skin patches were changed at the right intervals and found these were changed on the right days but the times were quite variable between the morning and evening. The records were not always clear if the time was am or pm as the 24 hour clock was not always used on the records. We were concerned that one person was due a patch change on the morning of the inspection but this was not marked on the new medicine administration record. At 11.30am the carer responsible for medication told us that she had changed all the medication patches for that day until we pointed out this particular case. At 2.30pm we noticed that the patch was still not changed and had to prompt the acting manager to deal with this and eventually this was done at 3pm instead at 8am. We were not sure that if we had not been in the home inspecting and pointed this out to the acting manger this would have been picked up so promptly. Since the last inspection the home has introduced regular checks (two or three times a day) of controlled medicines with two members of staff. We counted the stock of controlled drugs with the registered provider and this agreed with the entries in the record book with one exception. The home had reported to us that there were discrepancies between the records and stock checks of a 10mg tablet of a schedule 3 controlled drug. We found that this discrepancy was not clearly explained on pages 72 and 77 of the record book and stock balances were still showing that were not explained. One tablet was still not accounted for. The records need making clear what happened in line with the reports sent to us. One dose was signed for by two staff on the medicine chart but was not recorded in the controlled drug record book so it was not clear which record was correct. This can come about because of slack practice as observed on the day of the inspection where two staff had signed the record book for administering a dose at 9.55am but came back to sign the medicine administration chart at 11.30am. Medicine charts for the next four week period starting the day before the inspection were in use. We were concerned about inhaled medicines for one person where we saw the same drug was signed as administered as an inhaler and nebuliser solution. On checking the previous records we found that two additional medicines that are inhaled were included on the new medicine chart but had not been ordered. The manager began to investigate the reason for this and it appeared that the surgery had included two additional items in error on the repeat prescription. This was not identified by staff in the home or the pharmacy (who collect the prescriptions directly from the surgery so the home do not have a chance to check that the items they have ordered on behalf of people in the home are correct on the new prescriptions). Two doses of a new nebuliser solution were signed as administered yet the pack was full with no doses missing. One of the inhalers was signed as given once daily yet the directions were for twice daily regularly and this had been signed as such until two days before the inspection. We think
Care Homes for Older People Page 5 of 12 this was because the 8am dose was highlighted on the new chart but the evening dose was not. Three other inhaler medicines had directions for variable doses to use when required. There were no written directions in the care plan to give guidance to staff about how to reach a decision about what dose to use and when. We had received a response to the statutory requirement notice from the provider telling us that there were clearer guidelines for staff in relation to administration of medicines used as required that are documented in the care plans. We did not find this for any examples we looked for. We had provided advice about this at the inspection on 17 March 2009. We saw there were some additional sheets headed medication care plan but these only provided a space to record doses given and why so were not a protocol or plan to give guidance to staff about use. There was a procedure in place now so that to administer particular medicines prescribed to use as required, authorisation had to be obtained from the manager. None were in use at the time of this inspection. The manager told us he had discussed with the doctors about a number of medicines previously prescribed to use as required and these were now discontinued. We hope this was for the benefit of the people living in the home and not because the home did not want to make proper provision for the management of this type of medication. We pointed out one example where the medicine had been in use for some months. So that withdrawal effects are not experienced the dose is normally slowly reduced and not stopped abruptly. The registered provider showed us daily audit sheets she completes when she is there where she picks up on discrepancies with medication or other issues. She told us that she talks to staff about these and asks them if they are competent to give medication or need more training. Actions taken in response to the findings of audits need clearly recording so that any trends and lack of competence can be quickly identified and acted upon. There were also monthly audit checks in place and the acting manager was carrying out some of these when we started this inspection. As a result of these checks the home have officially notified us about discrepancies with medication. The acting manager has produced a revised medication policy in response to the March 2009 inspections. Also in dining room and medication room there were several internal memos with various procedures and reminders about different aspects of handling or administering medication. Staff had signed as read some of these. The acting manager also said the letter sent to us in response to the Statutory Requirement Notice was part of their medication policy. This information needs to be properly incorporated into one policy and procedure document so that there is clear information to staff about the way they have to deal with medication. This information states that two staff members carry out the administration of medicines but this was not happening on the day of the inspection so staff were not following the home policy. The registered provider and acting manager could provide no explanation for this. The Pharmacy had provided accredited medication training for five staff since the March 2009 inspections but not for the carer who was administering the medicines on the day of the inspection. She told us she had medication training but at another home. The registered provider and acting manager could not provide us any evidence of medication training for this person or that they had assessed her competence with medication. Other staff had been assessed for medication competence. In addition to medication issues the care of one resident was looked at. Information gathered about the resident by the home indicated that they may have dementia and this had been the situation before they came into the home. Episodes of confusion had also
Care Homes for Older People Page 6 of 12 recently been recorded in the residents daily record. The registered provider is reminded that the home is not registered for dementia care. The resident was spoken to and it was noted that they had a bruise on the back of their right hand. The bruise appeared to be recent although the resident was unable to recall how the bruise had happened. There was no record of the bruise in either the accident book or the residents care plan file. This situation was brought to the attention of the registered provider. The member of staff who had attended to the resident that morning was spoken to and they had not noticed the bruise that morning. Recently the home had recorded and reported to us a number of bruises that had occurred to residents although the bruise to the resident spoken to had escaped this recent vigilance. In addition it was noted that the residents fingernails were in need of cutting and cleaning. Examination of the care plan file showed that the residents finger nails had been clipped in May 2008, more recent recording of this could not be found. Another resident was spoken to and their fingernails were also in need of cleaning. The issue of cleaning residents finger nails has been raised at a previous inspection. During the inspection visit it was noted that there was a pile of unopened post in the managers office. On further investigation a second pile of unopened post was also found. Some items dated back to over a month previously. As well as residents both past and present, items of post were addressed to the registered provider and to the former registered provider and manager. What the care home does well: What they could do better:
The requirements of the Statutory Requirement Notice about medication issued on the 21 April 2009 must be fully complied with. Records about medication must be improved so that there is confidence that these are complete and accurate so that people living in the home always receive the right medicines in the right doses at the right times and are not put at risk because of poor record keeping. Accurate records must always be kept in the controlled drug record book. For each medicine prescribed with a variable dose or with a direction to administer as required there needs to be specific written guidance for staff to describe what this means for each person and medicine. Better arrangements are needed with the pharmacy to improve some information on the medicine administration records so that these accurately reflect the times when medicines are administered in the home, that the printed dose intervals are safe and that medicines that are discontinued are no longer included on the records. When handwritten entries are made on medicine charts these should all be signed and dated by the person writing them with a signed check by a second trained member of staff that the information is correct. Use of labels on medication charts is poor practice.
Care Homes for Older People Page 7 of 12 Improved arrangements are needed to check monthly repeat prescriptions to make sure that only the correct medicines are ordered and received. Arrangements must be put in place to make sure that medication that the manufacturers states needs to be kept in the fridge is always stored within the correct temperature range of 2 to 8 degrees centigrade and that records are kept to demonstrate this so that there is assurance that the medicines will be the right potency. The medicine policy, various local procedure memos and letters need bringing together so that there is clear direction to staff in one document. Some of the issues found during this inspection indicate that some staff may not still be fully competent to safely handle and administer medication so further training and competence assessment for dealing with medicines is needed. The regular audit checks that are already in place must be used in a more effective way to improve the arrangements for the handling and administration of medicines. The home should make more frequent checks on the condition of residents finger nails so that they can be cut and kept clean. Post must be distributed to residents or their representatives without delay. 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 8 of 12 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 7 15 (1) The registered person must ensure that all care plans contain clear instructions as to how the care needs of each resident are to be met. This is to ensure that care staff have the correct information to follow. The registered person must ensure that before a person starts work in the home, all the information and documents specified in Schedule 2 of the Care Homes Regulations are obtained. This is to safeguard people from possible harm. 31/07/2008 2 29 19 17/04/2009 Care Homes for Older People Page 9 of 12 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 1 9 18 Make sure that all staff who have any dealings with medication are fully trained and regularly assessed as competent to safely handle and administer medicines in this home. This is so that people living in the home are not at risk because of mistakes with medication. 23/06/2009 2 14 12 Residents or their 01/07/2009 representatives must receive their post addressed to them without delay. This is so that they receive important information and they or their representatives can exercise choice and control over their lives. 3 38 17 There must be a record of all 01/07/2009 accidents or injuries to residents. This is so that there is an accurate record of any accident or injury to a Care Homes for Older People Page 10 of 12 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 resident and of any treatment that they received. 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 1 2 7 9 The care of residents finger nails should be carried out more frequently. Make arrangements to see and check prescriptions in the home before they are sent to the pharmacy for dispensing. This can help the home to monitor what and when medicines are ordered, that the correct medicines are received and that the directions are current. Bring together in one coherent document the medicine policy, various local procedure memos and letters so that there is clear direction to staff about all aspects of the handling and management of medicines in this home. Do not use additional labels on medicine administration records and make sure that when any handwritten additions are made on the medicine administration record charts these are always signed and dated by the member of staff writing them with a second member of staff checking and signing as correct. 3 9 4 9 Care Homes for Older People Page 11 of 12 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. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 12 of 12 - 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!
