This inspection was carried out on 8th October 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: Hafod Residential Home Hafod Care Organisation 14 Anchorage Road Sutton Coldfield West Midlands B74 2PR one star adequate service 20/04/2009 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: Debby Railton Date: 0 8 1 0 2 0 0 9 Information about the care home
Name of care home: Address: Hafod Residential Home Hafod Care Organisation 14 Anchorage Road Sutton Coldfield West Midlands B74 2PR 01213556639 01213555688 hafodltd@aol.com Hafodlimited@aol.com 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) : Mr Alan Pearce care home 16 Number of places (if applicable): Under 65 Over 65 16 old age, not falling within any other category Conditions of registration: 0 The maximum number of service users who can be accommodated is: 16 The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 16 Date of last inspection Brief description of the care home Hafod Residential Home is registered to provide personal care for sixteen people aged 65 years and above for reasons of old age. The Home does not provide nursing care and does not have a category to care for people with dementia. The Home does not accommodate people who require the use of wheelchairs and hoisting equipment is not available for general use.
Care Homes for Older People Page 2 of 9 2 0 0 4 2 0 0 9 Brief description of the care home Accommodation is provided in a large adapted Victorian building situated at the junction of Anchorage Road approximately one mile from the centre of Sutton Coldfield. There are good bus links from Birmingham and Lichfield. There are 14 bedrooms, two of which are shared rooms however the Home utilises these as single rooms, and the majority have en-suite facilities. Bedrooms are located on the ground and first floors and a passenger lift gives access to these areas. Communal areas are available on both floors, these were spacious, attractive, well appointed and in keeping with the age of the property. A conservatory leads off the dining room looking out on to a well-maintained garden. Assisted bathing facilities are located on each floor offering a choice of bath or shower facilities and staff are available to provide assistance in these areas as required. There is limited off road parking at the front of the premises. There are notice boards located throughout the Home displaying forthcoming events and other information of interest to people who live there and their visitors in a large print format. A copy of our report was available on entering the home. Information relating to the services and facilities provided was available in individual bedrooms. Fee levels for the Home range from five hundred and forty five pounds to six hundred and eighty five pounds per week. Additional charges are made for hairdressing or chiropody. Care Homes for Older People Page 3 of 9 What we found:
Following an anonymous complaint regarding the mis-handling of medication a random pharmacist inspection was undertaken. The inspection lasted four hours. Six peoples medication was looked at together with their Medicine Administration Record (MAR) chart, care plans and daily records. All feedback was given to the manager, Janet Taylor, who was present throughout the inspection. Medication was stored in two places. The bulk of the medicines dispensed in a Monitored Dosage System (MDS), (where one tablet was dispensed in individual blisters for each dose), was kept in a locked cupboard. The remaining medication was kept in a small medicine trolley. During the medication round the relevant MDS rack of blister packs were placed on top of the trolley and taken round the home to adminsiter to the people who require their medication. Concern was raised that if an emergency occurred, the care assistant administering medicines may leave the medicines on top of the trolley unattended whilst dealing with the problem. All people in the home would have access to these unsecured medicines, which may increase the risk of harm. The majority of MAR charts were printed by the pharmacist. Staff had clear directions to follow and recorded what had occurred accurately on these MAR charts. Problems were seen when staff hand wrote MAR charts. Some were not dated so it was difficult to see when they related to. Others did not record the balances carried over from previous MAR charts, so audits were difficult to undertake, to demonstrate medicines had been administered as prescribed. One medicine was available for administration but there was no record of it on the MAR chart. It could not be demonstrated if it was no longer needed or that staff had forgotten to write it on the MAR chart. Some gaps were seen on the MAR charts. In one instance one medicine had not been administered and the reason for nonadministration not recorded, so the records were incomplete. This means that the people may not be adminsitered the prescribed medication at all times and so not receive the care they require. The care plans recorded basic information regarding the peoples clinical condition. Other records such as external health care professional visits had not been routinely recorded in the correct place. Whilst the manager had a good understating of the peoples clinical needs and staff actively sought medical assistance when necessary, all had failed at some point to record the visits and their outcome. Notes were sketchy and failed to record all the relevant details. It was possible though, to work out what had occurred and why but this would not help the next care assistant on shift to know exactly what had occurred immediately. Currently the manager does not have any quality assurance system to assess individual staff competence in their handling of medicines or check any of the MAR charts at the end of each cycle. Such audits would have identified these errors seen during the inspection. The majority of staff had received training in the safe handling of medicines. One person, to date, had not received the training but was due to go on the course soon. Care Homes for Older People Page 4 of 9 All Controlled Drug balances were correct and these reflected entries on the MAR chart indicating good practice. The complaint was very specific regarding the mal-administration of certain medicines. It could not be upheld as audits indicated that the care staff had administered these medicines as prescribed and acted on the directions from the doctor. 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 9 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 12 Care plans must provide sufficient information. So staff can assist people to meet all of their needs. 30/06/2009 2 8 12 Health care needs must be planned for. So peoples needs are met. 30/06/2009 3 38 18 Staff must be trained in fire safety. So they know how to protect people living in the Home from the risk of harm. 30/06/2009 4 38 23 The work place fire risk assessment must be updated. So people are protected from the risk of fire. 31/05/2009 Care Homes for Older People Page 6 of 9 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 13 Staff must transport 08/11/2009 medicines throughout the home in a safe manner and all medicines must be able to securely held in a locked facility in the event of an emergency This is to ensure that all medicines are safely held at all times to prevent mishandling. 2 9 13 A quality assurance system must be installed to assess staff competence in their handling of medicines. Appropriate action must be taken when these indicate that medicines are not administered as prescribed and records do not reflect practice. This is to ensure that individual care staff practice is assessed on a regular basis and appropriate action is taken if audits indicate that they do not administer the medicines as prescribed. 08/11/2009 Care Homes for Older People Page 7 of 9 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 3 9 13 The quantity of all medicines 08/11/2009 received and any balances carried over from previous cycles must be recorded. All MAR charts must be dated. This is to enable audits to take place to demonstrate that the medicines are administered as prescribed at all times. 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 9 It is recommended that two care staff hand write MAR charts. One to write and one to check the details are accurate. Care Homes for Older People Page 8 of 9 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 9 of 9 - 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!
