This inspection was carried out on 23rd July 2009.
CQC found this care home to be providing an Poor 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for older people
Name: Address: Heron Hill Care Home Esthwaite Avenue Kendal Cumbria LA9 7SE zero star poor service 26/05/2009 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: Angela Branch Date: 2 3 0 7 2 0 0 9 Information about the care home
Name of care home: Address: Heron Hill Care Home Esthwaite Avenue Kendal Cumbria LA9 7SE 01539738800 Telephone number: Fax number: Email address: Provider web address: peterw@abbeyhealthcare.org.uk Name of registered provider(s): Name of registered manager (if applicable) Abbey Healthcare (Huntingdon) Ltd Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 86 Number of places (if applicable): Under 65 Over 65 50 28 0 dementia old age, not falling within any other category physical disability Conditions of registration: 4 0 4 The home is registered for a maximum of 86 service users to include: up to 28 service users in the category of OP (old age not falling within any other category) up to 50 service users in the category of DE(E) (Dementia over 65 years of age) up to 4 service users in the category of DE (Dementia under 65 years of age) up to 4 service users in the category of PD (Adults with physical disabilities) Date of last inspection 2 6 0 5 2 0 0 9 Care Homes for Older People Page 2 of 8 Brief description of the care home Heron Hill is a new purpose built home caring for up to 86 people with nursing needs and it opened to residents in October 2004. It is in a quiet residential area with access to the bus routes and the train station. The town centre of Kendal is about 2 miles away. There is a car park at the front of the home. The home is on three floors and there is a passenger lift to all floors. All the bedrooms are single and have en suite bathrooms with showers. There are 2 communal bathrooms and toilets on each floor and separate communal lounges and dining rooms on each floor and an activities room on the first floor. The home has a statement of purpose and service user guide for prospective residents available on admission. A copy of the most recent inspection report is displayed on the notice board in the foyer of the home along with the results of the homes own satisfaction surveys and the complaints procedure. The scale of fees charged ranges from 633.31 pounds, plus nursing contribution (social services fees) to 831.30 pounds plus nursing contribution (private funded) as at the date of this inspection. There are additional charges to residents for hairdressing, private chiropody, papers and magazines and any personal toiletries. Additional charges for people living there who fund their own fees privately do not apply. Care Homes for Older People Page 3 of 8 What we found:
The service was visited in order to follow up requirements relating to medication that were made at the last pharmacy inspection on 26 May 2009. The pharmacist inspector assessed this through inspection of relevant documents, storage and meeting with staff. The inspection took approximately four hours. We checked handling of medication on Cavell Unit only and overall we found that this had improved. Records for the receipt, administration and disposal of medication were better maintained and more accurate to clearly show the treatment received by residents and reasons why medication was omitted. Where doctors made changes to medication these were clearly recorded in daily reports or communication sheets so that they could be easily tracked. These changes were accurately written up on medicines administration records and were double checked to reduce the likelihood of errors. Changes to medication were done promptly. Medication administration records were updated every four weeks. We checked that changes made on one record were accurately transferred to the next record at the start of the next four week cycle. While most of these changes were continued appropriately we saw a medication that had been stopped by the doctor that was restarted in error on the current medicines administration record. At the time of the inspection the resident had mistakenly received the medication for four days. Staff explained to us the new systems they use for checking medication changes however the problem we found shows that further work is needed to make sure residents are fully protected from errors. We counted a sample of medicines and compared the quantities with records to check that they tallied and to show that they were administered as prescribed. These samples were in order with the exception of one sample where records were unclear. We also saw one course of antibiotics that was continued in error for more than two days after it should have finished. Some medicines have specific requirements for administration either with food or on an empty stomach. We checked these and they were found to be given at the correct time as confirmed by staff and by records. We checked care plans for medication, particularly medication that was intended to be given only as needed for certain problems. Generally, these identified the correct use of these medicines so that residents received safe and effective treatment at the appropriate time. When medication was administered records also clearly showed the reasons why it was required. We checked medicines liable to misuse, called controlled drugs, on all three units and found the storage and records to be in order. The service managed controlled drugs well. Staff checked the stock of controlled drugs against records twice a day so that discrepancies could be identified quickly and dealt with. Staff who were spoken to said that they had recently received further training in medication provided by the supplying pharmacy and that this will shortly be repeated for those who were unable to attend the first time. We were told that the acting manager did regular checks, or audits, of medication to identify problems so that they may be dealt with promptly to keep residents safe. However, the results of these audits were not
Care Homes for Older People Page 4 of 8 recorded. The unit also did audits that were intended to be repeated weekly. However, the last audit on Cavelle unit was found to have been done nearly four weeks before the inspection. It is recommended that audits are more thorough. We watched how staff worked with, and helped, residents. While most residents were treated with kindness and respect we did see one occasion where this was not the case. The service must ensure that that residents are treated with kindness, dignity and respect at all times, that staff have good personal and professional relationships with them and are able to handle challenging situations. 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 There must be a system for checking for unexpected changes in medication. This was to be met by 16.6.08 This is to prevent errors being made and people getting the wrong treatment. This was to have been met by 16.6.08 and again by 01.07.09. 01/07/2009 2 38 37 The registered person must 01/07/2009 inform CQC without delay of any occurrence of injury, any theft and any event in the home which adversely affects the well being or safety of anyone living in the home. This will ensure that CQC is aware of any accidents or incidents in the home that might affect the safety or care of people living there 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 1 10 12 Staff must have good personal and professional relationships with residents and must be able to deal with challenging situations. This is to ensure that residents are always treated with kindness, dignity and respect. 28/08/2009 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 audits of medication are more thorough so that problems are identified and managed promptly. 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. 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 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!
