Inspection on 09/11/09 for Madeleine House

This inspection was carried out on 9th November 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 but made no statutory requirements on the home.

Other inspections for this house

Madeleine House 22/02/10

Madeleine House 19/10/09

Madeleine House 26/08/09

Madeleine House 24/06/09

Madeleine House 11/07/07

Madeleine House 24/08/06

Madeleine House 23/11/05

Madeleine House 05/05/05

Madeleine House 10/12/04

Madeleine House 09/06/04

Madeleine House 20/11/03

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Random inspection report Care homes for older people Name: Address: Madeleine House 60 Manor Road Stechford Birmingham West Midlands B33 8EJ zero star poor service 27/08/2009 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: Debby Railton Date: 0 9 1 1 2 0 0 9 Information about the care home Name of care home: Address: Madeleine House 60 Manor Road Stechford Birmingham West Midlands B33 8EJ 01217861479 01217850621 Telephone number: Fax number: Email address: Provider web address: www.anchor.org.uk Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Anchor Trust care home 41 Number of places (if applicable): Under 65 Over 65 0 41 41 dementia old age, not falling within any other category physical disability Conditions of registration: 10 0 0 The maximum number of service users who can be accommodated is: 41 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) 41 Physical disability - over 65 years of age (PD(E)) 41 Dementia (DE) 10 Date of last inspection Brief description of the care home Madeleine House is registered to provide residential care for up to 41 residents who are over 65 years of age and require assistance for reason of old age and physical Care Homes for Older People Page 2 of 11 2 7 0 8 2 0 0 9 Brief description of the care home disability. This includes ten residents who can be accommodated for reasons of dementia care. The Home is owned and managed by Anchor Trust. It is a modern two storey building set back off the road in its own grounds with adequate off road parking to the front of the building. It is well maintained internally and externally and is run as one unit. Care Homes for Older People Page 3 of 11 What we found: The pharmacist inspection lasted just under two hours. Eleven peoples medicines were looked at together with their Medicine Administration Record (MAR) chart. One care assistant was spoken with and all feedback was given to the project manager, care specialist and business manager. The reason for the pharmacist inspection was to check compliance with the Statutory Requirement Notice (SRN) issued on 16th September 2009, due to breaches in the regulations regarding the safe handling of medicines found at the pharmacist inspection on 19th August 2009. All the requirements left at this inspection had been fully met and the SRN fully complied with. This was commended. The home has finally sorted out the ordering of medicines from the many different doctors surgeries that look after the people living in the home. This has meant that all medicines are now ordered in time and action taken if any discrepancies are seen before the administration of any medicines. All MAR charts were well written, checked by a second member of staff for accuracy and the quantities of medicines received or balances carried over from previous MAR charts recorded enabling audits to take place. The home had installed a good quality assurance system that assesses overall practice in the safe handling of medicines as well as individual staff practice. A new system has been piloted in the home for staff to monitor their own practice. All these new systems now mean that the medicines are administered as prescribed and records reflect practice. The medication room has been moved to a different location in the home that does not have hot water heating pipes in it. The room now complies with current regulations, so all medicines are now safely stored in compliance with their product licences. People are encouraged to self adminsiter their own medicines and they are risk assessed as able, before they are allowed to do so and are regularly checked to ensure that they do so safely. All prescriptions are checked prior to dispensing and the dispensed medicines and MAR charts are checked for accuracy before any medicines are administered. The home has appointed new senior care assistants and we, the commission, were assured that they would undergo an induction and have support from agency staff until they were competent to perform the tasks required surrounding medication. What the care home does well: What they could do better: The home has responded well to the Statutory Requirement Notice issued and the standard of medicine management was good. Care Homes for Older People Page 4 of 11 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 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 3 14 The service must ensure detailed information is collated about peoples dementia and challenging behaviour so they can meet the persons needs. Not assessed atthis inspection 19/10/09 This will mean that clear management plans are put in place to care for people safely. 25/09/2009 2 7 15 Care plans must be generated from a comprehensive assessment detailing the actions staff need to take to ensure that all aspects of peoples needs are being met. Not assessed at this inspection 19/10/09 This will ensure staff have the information to monitor and review peoples changing needs. 25/09/2009 3 8 13 Peoples health and welfare 25/09/2009 must be monitored that includes peoples weight, specialist medical treatment, and any other instructions by Page 6 of 11 Care Homes for Older People 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 other health professionals deemed to ensure people stay healthy. This will ensure peoples current needs are know and will be met. 4 8 12 The service must ensure proper provision for the health and welfare of people living in the home and appropriate treatment is sought when concerns have been identified. This will ensure people receive treatment without delay. 5 8 17 Schedule 3 The service must 10/12/2009 ensure adequate records are maintained in respects of how peoples needs are being met and their health and welfare protected. This will ensure peoples needs are reviewed, and monitored as they change. 6 8 16 The home must follow the 10/12/2009 instructions from other health care professionals in the event of people requiring additional support with their dietary needs. This must be reviewed and additional support sought if required. Records must also demonstrate that food intake and fluid intake is monitored appropriately. 10/11/2010 Care Homes for Older People Page 7 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 This will ensure other health care professionals are involved when required. 7 15 16 People must have a choice of 25/09/2009 meals available to them at all times in particular people who do not have their meals in the communal areas. This will ensure their dietary needs are met. 8 16 22 All complaints must be logged and thoroughly investigated. Not assessed at this inspection 19/10/09 This will ensure peoples views are listened to and actions taken to address their concerns. 9 27 18 An assessment of peoples 25/09/2009 dependency on assistance or supervision must be undertaken to be sure there is enough staff to meet peoples needs and wishes taking into consideration the size and layout of the building. Not assessed at this inspection 19/10/09 This will ensure people receive assistance and supervision when they need and wish. 10 30 18 Training undertaken by staff 25/09/2009 Page 8 of 11 25/09/2009 Care Homes for Older People 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 must be monitored to ensure what staff have understood is put into practice. Not assessed at this inspection 19/10/09 This will ensure staff professional development and mean safe working practices at all times. 11 31 8 An application must be submitted to the Care Quality Commission for the position of registered manager. Not assessed at this inspection 19/10/09 This will ensure the day-today management of the home is undertaken in the best interest of the people who live there. 12 33 24 An effective quality 25/09/2009 assurance system that is robust and identifies where there are failures in the service provision must be set up. Not assessed at this inspection 19/10/09 This will ensure action is taken quickly to address issues of concern. 25/09/2009 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 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. 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. 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