Random inspection report
Care homes for older people
Name: Address: Hill Ash House Hill Ash House Ledbury Road Dymock Glos GL18 2DB one star adequate service 09/01/2009 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: David Jones Date: 0 5 0 6 2 0 0 9 Information about the care home
Name of care home: Address: Hill Ash House Hill Ash House Ledbury Road Dymock Glos GL18 2DB 01531892980 01531890767 mpearce@ehguk.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) : European Healthcare Operations Ltd care home 36 Number of places (if applicable): Under 65 Over 65 36 36 old age, not falling within any other category old age, not falling within any other category Conditions of registration: 0 0 The maximum number of service users who can be accommodated is 36 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. The registered person may provide the following category of service only: Care Home with Nursing - Code N 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
Care Homes for Older People 0 9 0 1 2 0 0 9 Page 2 of 14 Brief description of the care home Hill Ash House is an extended Grade 2 building, set in its own extensive grounds. Following a change in the homes registration it now offers personal care only to older people. There are ample communal rooms and bedrooms are single with ensuite facilities. A shaft lift offers access to the upper floors. Specialised equipment is provided to meet differing needs and external health care professionals such as the GP, Dentist Chiropodist are contacted as required. There are extensive grounds that can be enjoyed by the residents in the milder weather. The local bus stops in the village of Dymock, which on foot is some distance from the home. Information about current fees was not obtained during this inspection. Copies of the homes Statement of Purpose and Service Users Guide are displayed in the main entrance to the home. Care Homes for Older People Page 3 of 14 What we found:
At this random inspection one of our (the Care Quality Commission) pharmacist inspectors examined some of the arrangements for the handling of medicines following some concerns found at the last key inspection in January 2009. We looked at some stocks and storage arrangements for medicines and various records about medication. We saw how staff administered some medicines and we talked to some people living in the home. We spoke to the manager designate, deputy manager and two carers who were trained and authorised to handle medicines. The inspection took place during a five hour period on a Thursday (4th June 2009). We gave full feedback to the manager designate about the medication issues we found on the following day. We thank the staff for their assistance during our visit and the positive way in which they approached this inspection. At the time of this inspection no people living in the home were assessed as able to self medicate and look after their medicines so they were totally dependent on the staff for this part of their care. Certain carers who had specific training were responsible for handling and administering all medicines for people living in the home. Staff told us that sometimes people have been helped to look after their medicines if they wished to and where an assessment showed this was safe. Some staff were doing more in depth training about the safe handling of medicines and the manager designate said she was trying to find further training. As noted at the last inspection this has been a challenge for staff who have taken on this as a new responsibility following the home changing registration to a care home providing personal care. The staff we spoke to clearly took these responsibilities seriously. During the course of our inspection we saw that staff gave medicines to people living in the home within an acceptable period of the time shown on the medicine directions and followed safe procedures. We saw that at lunchtime some people were still in the dining room when a member of staff came to give them some medicines. They had finished their lunch and many were enjoying a cup of tea or coffee. We discussed with the manager designate about finding out about each persons choice about how they wanted their medicines and if they felt it respected their dignity and privacy to have their medicines administered in public in the dining room at a meal time. Staff told us they would not administer medicines such as inhalers or eye drops at a meal time. Special consideration is needed for any medicines that have to be given before food. We also discussed with staff the need to be very careful to make sure that for medicines containing paracetamol there is always a minimum of four hours between each dose so as to avoid risks of toxic effects. The printed times on the medicine charts often showed just a four hour interval. Staff told us they generally complete the morning medicines by 9.30am so anyone having a dose of paracetamol at this time and due for another dose at lunchtime should not have this until 1.30pm rather than 12 noon as printed on the charts. On the day of the inspection a carer began giving the lunch medicines at 12.45pm. Staff told us about one person where night staff gave the morning paracetamol dose earlier as this person was awake. This helped to space the doses more evenly throughout the day so giving a better effect from the medicine. Two staff administered the morning medicines, the time when a lot of medicines were given. Two medicine trolleys were used all of which has helped to give the medicines more promptly. One person we spoke to confirmed that staff always give him/her their medicines.
Care Homes for Older People Page 4 of 14 There were 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. Accurate, clear and complete records about medication are very important in a care home so that people are not at risk from mistakes with their medicines and so that there is a full account of the medicines the home is responsible for on behalf of the people living there. We looked at some of the medicine records and were concerned to find that these were not always kept to a good standard. For example we found that although generally staff signed the medicine charts when a medicine was administered there were a number of gaps on the records so it was not possible to tell if the person had had their medicines correctly. In one case we saw that the tablet was missing from the pack for the day and time when there was a gap on the chart; this could possibly (but not necessarily) indicate the medicine was given. In another case the medicine chart had not been signed since 18th May 2009 against some eye drops; there was an unopened bottle of these drops in the fridge and another opened bottle in the medicine trolley. Staff were not sure if this person should be having this treatment. There was nothing in the care plans about this. The senior carer said she would contact the doctor to find out. It was not always possible to see how much of a medicine people had received where a variable dose (one or two tablets for example) was prescribed. We did see other records where this was done properly. One handwritten record did not include the strength of one of the tablets (available in at least three different strengths). This was despite two staff signing as checking the entry. The directions for some medicines were not always clear on the labels or medicine charts and sometimes included instructions like as directed. Some directions for eye drops did not state if these were for use in the left, right or both eyes. The records for one person showed that staff were signing as instilling two different artificial tear drop products at 10pm each evening; this was probably not a suitable way to be using these drops. Some charts had details of medicines printed that were no longer in use. The medicine charts were printed by the pharmacy each month and staff told us they complete the proper forms to ask the pharmacy to update the charts but this does not always happen. The allergy section on a number of medicine charts was blank. The dose of a certain medicine (where there were regular changes following a blood test) was only taken over phone and not confirmed in writing as specified by the National Patient Safety Agency. Staff were not aware of this so we left further information for them to follow up. We looked in some care plans to see what further guidance was included to staff to help with making decisions about using medicines that were prescribed to use when required or with a variable dose. Although there was a section for medication this did not provide this sort of information. We also looked for some people with more specific health needs to see what the care plan included. We found that the information was not always specific enough and sometimes did not even include use of the medicines. For example no mention about using a laxative in a care plan for continence or a care plan about skin care included creamed without specifying what creams. During the inspection we identified that two medicines for one person were not in stock. Staff had taken appropriate action to deal with this. Records for another person show that staff had administered some doses of a laxative that was not prescribed nor included in the list of medicines the staff can give as a homely remedy without a prescription. This particular medicine is supposed to be used regularly and not taken as odd doses when required. Care Homes for Older People Page 5 of 14 Our checks of the controlled medicines record book showed that there were anomalies on some pages (8,10,11,12) that needed further investigation in order to clarify what was recorded. The acting manager told us when we pointed some of these out that she was aware of some of the reasons. We looked at the storage arrangements provided for medicines and found there were some matters that needed attention. The lock on one cupboard needed repairing as the key could not be removed from the lock so the medicines in this cupboard could not be secured. Staff told us the door to the office was kept locked. One of the medicine trolleys kept in a public area was not clamped to the wall when not in use.There were two new clamps but these needed fitting. The controlled drug cupboard needed securing to the wall with rag or rawl bolts in order to comply with the appropriate regulations. This cupboard must be used only for storing controlled medicines; we found some loose blisters of tablets and some other items other than medicines presumably put in here for safe keeping. There was a special fridge for keeping medicines and records showed this was running at the right temperature. We noted that all eye drops were kept in the fridge but this is only necessary for a very few items where the manufacturer will specifically state this. Generally eye drops are best stored at room temperature as this is more comfortable when the drops are instilled. The drops must be used within 28 days of opening to prevent risks from contamination. We saw that the bottles in use had an opening date so that staff knew when to change the drops. Records of the temperature in the room medicines were stored in showed that this was within a safe range. Some staff showed us various records about audits for medicines that they carry out. We discussed ways of improving these audit checks by considering combining some records and to always include the actions taken as a result of the findings from the audit in order to make improvements. The pharmacy supplied many medicines in special packs that last for four weeks and make checks easy to see that the medicines have been taken from the pack on the right day and time. When medicines are not packed in these monitored dose system packs it is good practice to write the date on any of these containers when they are first used. This makes it possible to see the stock is used within defined periods and also to allow counts of the stock remaining as a check that all the medicines can be accounted for and indicating if people have been given the right dose. What the care home does well: What they could do better:
Improve the medicine records to make sure these are always accurate, clear and complete. There must be no gaps on medicine charts for any medication that is administered regularly. The chart must be signed as soon as the medicines are seen as taken or a standard code used to explain missed doses. The actual dose of medicine given must be recorded where a variable dose is prescribed. Directions on eye drops must state which eye(s). Staff must mark the administration charts to be quite clear if a medicine is no longer in use and press the pharmacy to make sure that the printed
Care Homes for Older People Page 6 of 14 medicine charts they provide are kept up to date with the information provided by the home. Arrange to include appropriate information in the allergy box on the medicine charts (even if this is none known) as this indicates this important matter has been considered. Dose changes of warfarin to be confirmed in writing in accordance with guidance published by the National Patient Safety Agency. Further written information must be provided to guide staff about the use of medicines that are prescribed to use when required or as directed or with a variable dose. Consideration of the requirements of the Mental Capacity Act 2005 must be included. Care plans could usefully include information about peoples choices about how and when they want to take their medicines. Always keep accurate and complete records in the controlled medicine record book. Repair the broken lock on one of the medicine cupboards and arrange to fix the special medicine trolley clamps already purchased so that these trolleys can be secured when not in use. Replace the fixing screws inside the controlled medicine cupboard with rag or rawl bolts. Review and improve the medication audits to make them more effective. Record the actions taken to address any shortfalls found by the audit process so as to protect people living in the home from risk of mistakes with medicines. Write the date on medicine containers when they are first used to help with proper stock rotation as advised by the manufacturer or pharmacy and to help with more effective audit checks. Arrange to review the homely remedy protocols as some medicines included may not be appropriate and make sure staff only use those medicines included within the protocol. Please note, outstanding statutory requirements 1 to 5 listed below were not followed up at this specialist medication inspection so are still listed. These will be checked as properly actioned at a future inspection. 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 14 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 Residents must have care plans for all their assessed needs. This is so that staff have clear information on how a residents needs can be met. Not inspected at random inspection on 4th June 2009 but will be checked as properly actioned at a future inspection. 30/04/2009 2 8 13 Where residents have needs in respect of moving and handling then a risk assessment must be completed by the home. This is so that staff have clear information on how a residents moving and handling needs can be met in a safe way can be met in a safe way. Not inspected at random inspection on 4th June 2009 but will be checked as properly actioned at a future inspection. 30/04/2009 3 16 17 A record must be kept of all complaints received by the home and of any action 30/04/2009 Care Homes for Older People Page 8 of 14 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 taken in respect of these complaints. This is so that the home can demonstrate that any complaints have been investigated in the interests of people using the service. Not inspected at random inspection on 4th June 2009 but will be checked as properly actioned at a future inspection. 4 29 19 Before a person starts work in the home, all the information and documentation specified in Schedule 2 of the Care homes Regulations 2001 must be obtained. This is to ensure that residents are protected through robust recruitment procedures. Not inspected at random inspection on 4th June 2009 but will be checked as properly actioned at a future inspection. 5 33 26 Reports of visits made by the 30/04/2009 registered provider must be kept in the home. This is so that they are available for inspection and for the reference of the manager of the home. 30/04/2009 Care Homes for Older People Page 9 of 14 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 Not inspected at random inspection on 4th June 2009 but will be checked as properly actioned at a future inspection. Care Homes for Older People Page 10 of 14 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 Make arrangements to improve the storage arrangements for medicines so as to reflect current legislation and best practice guidance. This is to make sure the shortfalls about medicine storage identified at this inspection are corrected so that all medicines are always stored safely and do not present a risk to anyone in the home. 05/07/2009 2 9 13 Always keep accurate and complete records in the controlled drug record book. This is to help make sure that all these medicines are properly accounted for and people have received the correct doses. 05/07/2009 3 9 13 Always keep accurate, clear and complete records about any medication kept in the home and administered to people who 05/07/2009 Care Homes for Older People Page 11 of 14 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 live in the home. (This particularly refers to the shortfalls identified in the report). This is to help make sure all medicines are accounted for, that people receive their prescribed medication correctly and are not at risk of mistakes with medication because of poor recording arrangements. 4 9 13 Review medicine records and 31/07/2009 care plans for people living in the home to make sure that for all medicines prescribed with a direction when required or with a variable dose there is clear, up to date and detailed written guidance available to staff on how to reach decisions to administer the medicine and at a particular dose, taking into account the provisions of the Mental Capacity Act 2005. This will help to make sure people living in the home receive the correct amounts of medication in a consistent way in line with planned actions. Care Homes for Older People Page 12 of 14 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 9 9 Make sure the medication audit process always includes action taken to address any shortfalls identified. Review the storage of eye drops in the fridge and change this in accordance with information provided by the manufacturers. Care plans should reflect what choices people who live in the home were given and have made about how their medicines are administered and their consent to the way in which staff administer their medicines. (This particularly relates to the administration of some medicines during meal times and in a public area.) Review the medicines included in the homely remedy protocols so as to reflect current best practice guidance. Arrange to use the standard yellow anticoagulant record book and for dose changes of anticoagulants to be confirmed in writing by the prescriber as detailed in Patient Safety Alert 18 from the National Patient Safety Agency. Make arrangements so that all staff write the date on any containers of medicines when they are first opened to use. This helps with good stock rotation in accordance with the manufacturers or good practice directions and with audit checks that the right amount of medicines are in stock. 3 9 4 5 9 9 6 9 Care Homes for Older People Page 13 of 14 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 14 of 14 - 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!
