Random inspection report
Care homes for older people
Name: Address: Havencroft Nursing Home Lea End Lane Hopwood Birmingham West Midlands B48 7AS zero star poor service 04/03/2010 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: Christine Potter Date: 1 8 0 5 2 0 1 0 Information about the care home
Name of care home: Address: Havencroft Nursing Home Lea End Lane Hopwood Birmingham West Midlands B48 7AS 01214452154 01214452159 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Lesley Ann Owen Type of registration: Number of places registered: Conditions of registration: Category(ies) : Regal Care Limited care home 32 Number of places (if applicable): Under 65 Over 65 32 0 old age, not falling within any other category physical disability Conditions of registration: 0 32 The maximum number of service users who can be accommodated is: 32 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: Old age, not falling within any other category (OP) 32 Physical disability (PD) 32 Date of last inspection 0 4 0 3 2 0 1 0 Care Homes for Older People Page 2 of 11 Brief description of the care home Havencroft Nursing Home is a large, Victorian building. It is located just off the main road in the village of Hopwood. Hopwood is close to the boundary of Birmingham easily accessible from junction two of the M42 motorway. A limited bus service which stops within walking distance of the home is available for visitors. The home is registered to provide nursing care for up to 32 people who require 24 hour nursing and personal care. The home is equipped with specialist equipment to assist the staff in meeting the health and personal care needs of the residents. This includes a range of pressure-relieving mattresses to help prevent the development of pressure ulcers, and mobile hoists to help people move from, for example, their bed to their wheelchair if they have limited or restricted mobility. Accommodation is provided on three floors in both single and shared rooms. A lift is available to assist people using the service to access all areas of the home. Communal areas are available, the owners have recently provided an extra lounge with dining area. This is in addition to the other lounges so residents have a choice of where they wish to spend their day. A garden is available for the people to use when the weather permits. The registered providers are Regal Care Limited, and the registered manager for the home is Lesley Owen, who is a first level registered nurse with many years experience working in both the National Health Service and the private sector. Information regarding the home can be obtained from the Statement of Purpose and the Service Users Guide which are available from the home. Information regarding fees for the Home should be requested direct from the manager or from the owners. Care Homes for Older People Page 3 of 11 What we found:
This unannounced random inspection of Havencroft Nursing home was carried out on the 18th May 2010. There were two inspectors from CQC including the pharmacist inspector to monitor compliance with the medication requirements. The reason for the inspection was to monitor the homes compliance following the last key inspection on the 4th March 2010. Following this inspection the home had failed to show sufficient progress and remained on poor quality rating, and a warning letter was issued. This gave the home timescales for them to comply with the outstanding requirements regarding the management of medication, and health and welfare residents. There were 25 people being accommodated on the day of the inspection. We met with the deputy manager, clinical lead nurse and care staff. We reviewed care records, staff records, and the homes internal auditing systems. Choice of Home: (standards 1 - 6) We looked at the pre admission assessment for two people that had been admitted following the agreement from the local authority for the home to admit people again. The manager and deputy manager had completed the pre admission assessment form. This contained sufficient information for the home to develop a basic care plan, and provide information to the staff about the person being admitted. The deputy manager was aware of the health and welfare needs and why they had been admitted into the home. We received anonymous complaints that people had arrived at the home and staff were not aware that they were arriving and had not made any preparation for them. The deputy manager could not explain the reason for this, but acknowledged the importance of ensuring people are aware of peoples health and welfare needs prior to them being admitted into the home. The nurse on duty confirmed that communication had been an issue, but felt over the last two weeks there had been noticeable improvement. The other standards from this section were not assessed at this inspection. Health and Personal Care (standards 7 - 11) A plan of care was in place for all people living in the home. We looked in detail at three peoples care records. From the last inspection the service has implemented time for the documentation to be improved. There were still inconsistencies and the accuracy of the records was discussed. For example the pharmacist inspector identified that three people had not received their prescribed medication correctly. However the daily records in the individuals care plans stated that they had taken their medication. This could result in the persons health and personal care needs not being fully met by the staff. We received an anonymous complaint that the home had failed to respond appropriately following an accident that had occurred in the home when someone was being assisted to move with the lifting hoist. The deputy manager confirmed that this had been addressed and health and safety had been informed of the accident. Records showed that the hoist had been serviced at the correct time, and a maintenance person from the company
Care Homes for Older People Page 4 of 11 visited the home to repair the hoist. The deputy confirmed that the staff using the hoist had been trained in moving and handling. This incident has been referred to the safeguarding authority, but the outcome of their investigation is not yet known. The deputy manager confirmed that the family had been informed about the accident and the action being taken by the home. One complaint received following the last key inspection in March 2010 was referred to the safeguarding team. This was an allegation of neglect and the person was transferred to hospital and then moved into another home. The outcome of this investigation is not yet known. The outcome of this will be included in the homes next inspection report. The management of medication was reviewed by the pharmacist inspector. This raised concerns that people were not receiving their prescribed medication correctly and no reason for this could be given by the acting manager and clinical nurse on duty other than they were out of stock. Examples included the nurses had failed to record the amount of sinemett received into the home or carried forward from the last month. The nurses had recorded code o was on the MAR chart from 03/05/2010 to 07/05/2010 and also from 13/05/2010 to 18/05/2010. The code o was defined at the bottom of the MAR chart as Not received from pharmacy. The pharmacy inspector read that ten doses had been recorded as administered from 1800 hours on 07/05/2010 to 1800 hours on 12/05/2010. The pharmacy inspector also read that there was a code o recorded at 0830 on 12/05/2010. On another persons hand written Medication Administration Record, Betahistine as commencing 04/05/2010, the pharmacist read that prescribed Betahistine 16mg tablets were to be administered at a dose of one three times a day. The o (out of stock) had been recorded for the last five doses for 17/05/10 and 18/05/10. The pharmacist found that none were available to administer on the premises. The nursing staff had failed to order a prescription in time to ensure a continuous supply of Betahistine 16mg tablets. Evidence of the medication errors was seized using code B notices and we shall be seeking legal advice as to whether to issue statutory requirement notices, given this requirement is outstanding from the last key inspection. The home had failed to inform the individuals doctor which could have resulted in their health care needs being compromised. An immediate requirement notice was issued for the home to inform the doctor, refer to safeguarding and provide the medication for the residents within the next 12 hours. We visited the home on the 20/05/2010 and the immediate requirement notice had been complied with. There were inaccuracies with the amount of medication in the home, when audited against the Medication Administration Record, and the number of tablets administered. The other standards from this section were not reviewed at this inspection. Daily Life and Social Activities (standards 12 - 15) At the time of the inspection people were seen in various parts of the home. The activities organiser is employed for ten hours a week, which is difficult to ensure that peoples social
Care Homes for Older People Page 5 of 11 care needs are met over the seven days. The care records failed to include risk assessments for people going out of the home. Complaints and Protection (16 - 18) The complaints procedure in the entrance to the home has been updated since the last key inspection. The home worked closely with the care quality team, and the voluntary ban on admissions was lifted. We have received written concerns that the home failed to meet the healthcare needs for one person resulting in them being admitted to hospital, and being transferred to another home. This is being investigated by the Multi Agency Safeguarding team. The outcome of this investigation is not yet known and the results will be included in the inspection report. Following this inspection a safeguarding referral was made about the concerns around medication. Environment: (19 - 26) These standards were not assessed at this inspection. Staffing: (27 - 30) We were informed that there were 17 people living in the home on the day of the visit. We looked at the staff duty Rotas for the home. The acting manager told us that the clinical competencies for the nurses had not been reviewed. The staffing levels were within the minimal guidance for the number of people being accommodated. Staff spoken to confirmed that the levels were sufficient to meet the needs of the people. However, given the concerns around medication, the competencies of the nursing staff is again brought into question. Whilst appreciating that some agency nurses have been covering shifts, the homes permanent nurses failed to act on the issues around medication shortfalls. The deputy manager told us that she was arranging for a nurse from one of their other homes to come over to assess the clinical competencies of the nurses working in the home. We were told the date of the next scheduled staff meeting. Management and Administration (31 - 38) In the last two weeks the home has nominated the deputy manager into the acting manager role so that the registered manager can concentrate on addressing the shortfalls with the peoples care records. We were informed that the manager from another home is going to visit the home to assist in assessing the clinical competencies for the nurses working in the home. Mr Takhar, the responsible individual, is visiting the home regularly and completing monthly statutory reports which were shown to us at the time of the inspection. Systems are being developed for auditing care plans and medication. The documentation for supervision of staff has been changed to provide a more effective monitoring system. All staff spoken to on the day of the inspection were committed in improving the standard
Care Homes for Older People Page 6 of 11 of the home and to provide a better quality service for the people living in the home. 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 7 of 11 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 Regulation 13 2 The service 31/03/2010 must ensure that medication administration are accurately maintained, that the reasons for non- administration of medication are clearly recorded by the time entry on the medication record, that the meaning of any codes are clearly explained on each record, and that the person completes the medication administration record at the time of administration. This is to ensure that people who live in the service are protected and have their prescribed medication correctly. Not complied with 18/05/2010 2 9 13 Regulation 13 2 The service 31/03/2010 must make arrangements to ensure that all records are kept of all medicines received, administered and disposed of to ensure that accurate checks can be made on peoples medication. to ensure that they can account for peoples Care Homes for Older People Page 8 of 11 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 prescribed medication at all times. Not complied with 18/05/2010 3 27 18 The home must be able to 19/04/2010 demonstrate that the nurses working in the home have the skills and competencies to meet the health and personal care needs of the people living in the home. To protect the people living in the home. The home has not complied with the requirement 18/05/2010 4 33 35 The home should develop a system to monitor the internal systems. To assist ensuring peoples needs are being met. Partly complied with 18/05/2010 30/04/2010 Care Homes for Older People Page 9 of 11 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 Reg 13 2 people receive their prescribed medication correctly. To ensure that their health care needs are not compromised 30/07/2010 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 10 of 11 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 11 of 11 - 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!
