This inspection was carried out on 16th March 2010.
CQC found this care home to be providing an Good 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for older people
Name: Address: Holmwood Care Centre 30 Chaddesley Road Kidderminster Worcs DY10 3DJ two star good service 13/08/2009 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: Morag Ross Date: 1 6 0 3 2 0 1 0 Information about the care home
Name of care home: Address: Holmwood Care Centre 30 Chaddesley Road Kidderminster Worcs DY10 3DJ 01562824496 01562822935 admin@holmwood.plus.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Gail Elizabeth Gilbert Type of registration: Number of places registered: Conditions of registration: Category(ies) : St Cloud Care Plc care home 60 Number of places (if applicable): Under 65 Over 65 40 1 60 60 dementia learning disability old age, not falling within any other category physical disability Conditions of registration: 0 0 0 5 Accommodation to be used for a maximum of 45 nursing places. Category PD is restricted to persons aged between 55 -64 years. The home may accommodate one named service user over the age of 50 years with learning disability (LD). Date of last inspection 1 3 0 8 2 0 0 9 Care Homes for Older People Page 2 of 10 Brief description of the care home Holmwood Care Centre is a 60-bedded care home situated a short distance from the centre of Kidderminster. The home has 56 single rooms with many offering en-suite facilities, the service can also accommodate people who wish to share a room. Accommodation is provided on three floors with a passenger lift providing access to rooms on the upper floors. Other areas of the home used by people include, lounges, dining room, toilets and bathrooms. Handrails are appropriately fitted to assist people to walk around the home. Ramps are fitted to assist people in wheelchairs to go outside to the enclosed garden. The registered manager for the home is Mrs Gail Gilbert who is a first level registered nurse and many years experience working in care for the elderly. Gail has completed the Registered Managers Award. The home is owned by St Cloud Care PLC and the providers takes an active role in the home and the people who live there. A range of activities are provided for the people living at the home and assist people to maintain links with the local community. Information about the fees are not included in the Service User Guide, for up to date information about the fees please contact the home direct as the fees are based on individual needs and assessments. Additional charges are made for hairdressing, daily newspapers and chiropody. Care Homes for Older People Page 3 of 10 What we found:
The pharmacist inspector visited the home on 16th March 2010 to undertake a random inspection in order to check the management and control of medicines. We looked at medication storage, some care records and medication administration records. We spoke to two members of staff and the manager. We were in the home for four and a half hours. Medication was stored within locked cupboards in a locked treatment room. There was a locked medicine trolley on each of the three floors to store peoples medicines. This means that there was provision for the safe storage of peoples medication. We found a lack of stock control and rotation of peoples medication. The service had just received their medicine delivery for the month of March, however we found that some recently delivered medication was not required due to the large amount already available in the cupboards. For example, we counted 79 boxes of paracetamol for 16 people stored in one stock cupboard. There was no order or control to the storage. We counted 12 boxes of paracetamol for one person dating back to July 2009. We saw that later dated boxes were at the back of the cupboard and were not brought forward in order to be used first. We found five boxes in the cupboard for two people who were deceased. We discussed our findings with the manager who agreed that this was not acceptable, however did explain that storage of medicines was an overall problem that was being discussed with the supplying pharmacy. This means that the stocks of medicine were not checked or controlled and therefore there was an increased risk of a medication error. Medication that should be disposed of was not always removed for safe destruction. For example, we saw a paper bag containing two boxes of injections for a person who was deceased. We discussed these findings with the manager who agreed that the medication needed to be removed from the cupboard and destroyed. This means that medication, which was no longer required, was still available in the service. This means that there is a lack of safe medication management and control of peoples medication and therefore increases the risk of an error. We found envelopes containing peoples money and valuables stored inside a medicine cabinet. We showed this to the manager who agreed that this should not happen and there was separate safe storage available for peoples money and valuables. This means that there was an increased risk of unecessary access to peoples medicines and money and valuables were not stored correctly. Prescribed medication for named people was not always available in the medicine trolley to give to people as prescribed by their GP. For example, we could not find one persons prescribed medicine for the prevention of vitamin D deficiency in the medicine trolley. We were informed by a member of staff that the medicine trolley was too small to store every persons medicine and therefore one box was used for everybody. We found that one persons prescribed medicine, which was labelled for them, was being used to give to other people prescribed the same medicine. We were informed that this practice was also used for another two medicines where more than one person was prescribed it. We discussed these findings with the manager who agreed that this was not good practice. we acknowledged the problems in storing many medicines in the trolley but it is not good
Care Homes for Older People Page 4 of 10 practice to use one persons medicine to give to other people. We were not able to check the medicine to ensure it had been given to the person and therefore we could not evidence that the medicine had been given as prescribed. We found that the medicine records were not always documented with the receipt or balances of medicines available, which made it difficult to check whether medicines had been given to people living in the home. This was particularly seen for medicines available in a box or a bottle. For example, we looked at one person who was prescribed seven different medicines. We checked the amount of tablets or capsules available in the home and checked the amount of medicines given according to the Medication Administration Record (MAR) chart. Four of the medicine checks were correct. Three medicines could not be checked due to the following issues. One tablet was not available in the medicine trolley for the person, however another persons labelled medicine was being used. One tablet could not be checked because the date of opening of the box was not recorded and the amount of tablets removed did not match the receipt records or the MAR chart. One tablet was available in a bottle in the door of the trolley and a further second supply was available in a pre-packed blister from the pharmacy. The total amount available in the home did not match with the receipt records. This means that due to poor records it was not clear if the person had been given three of their prescribed medicines. Personal care plans were not kept up to date with information relating to peoples medication. We looked at two peoples care plans with regard to medication. The first care plan did not document that the person was taking an anticoagulant medicine which is used to thin the blood and requires regular blood checks. We were informed by a member of staff that a District Nurse came from the local GP surgery to check the bloods. This information was not documented in the persons care plan. The second person was prescribed a medicine to be given for anxiety when necessary. We saw an action plan which detailed how to help the person control their breathing but there was no record to show when the tablet should be given and under what circumstances. We discussed these findings with the manager. This means that the care plans were not kept up to date with regard to peoples medication which increases the risk to their health and welfare. What the care home does well: What they could do better:
The service needs to ensure that all medication is administered as directed by the prescriber to the person it was prescribed, labelled and supplied for. This is to ensure that people get their medicines correctly. The service needs to make arrangements to ensure that care plans include detailed information and instructions for staff with regard to peoples medicines. The service needs to make arrangements to ensure that records are kept of all medicines received, administered and leaving the home or disposed of. The service needs to make arrangements to ensure there is an effective system in place
Care Homes for Older People Page 5 of 10 to request, obtain and retain adequate supplies of prescribed medicines so that stock levels are kept at a safe level. 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 6 of 10 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 27 18 Given the size and layout of the home, and the numbers and dependencies of people receiving nursing care, the staffing levels and skills mix are in need of review. To ensure that the health care needs of the nursing residents are not compromised. Remains outstanding 14/09/2009 Care Homes for Older People Page 7 of 10 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 The service must make 30/04/2010 arrangements to ensure that records are kept of all medicines received, administered and leaving the home or disposed of. This is to ensure that the care service maintains accurate records of medicines received and disposed of. The service must make 30/04/2010 arrangements to ensure that care plans include detailed information and instructions for staff in respect of administration and management of medicines, including the reasons to give medicines when required and what constitutes needed for the named person. This is to ensure that there are clear directions for staff to give medicines prescribed when required. 2 9 13 Care Homes for Older People Page 8 of 10 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 service must make 30/04/2010 arrangements to ensure that all medication is administered as directed by the prescriber to the person it was prescribed, labelled and supplied for. This is to ensure that people get their medicines correctly and that procedures for medicine administration are safe. 4 9 12 The service must make 30/04/2010 arrangements to ensure there is an effective system in place to request, obtain and retain adequate supplies of prescribed medicines so that stock levels are kept at a safe level. This is to ensure the amount of medicines stored within the service is a safe level to ensure the health and welfare of people. 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 9 of 10 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 10 of 10 - 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!
