Inspection on 14/04/10 for Manor Court

This inspection was carried out on 14th April 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Court 06/07/10

Manor Court 26/04/10

Manor Court 23/02/10

Manor Court 14/03/08

Manor Court 26/02/07

Manor Court 30/06/06

Manor Court 18/10/05

Manor Court 27/04/05

Manor Court 04/11/04

Manor Court 04/08/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 29/06/2010.

Random inspection report Care homes for older people Name: Address: Manor Court 31 Churchfield Lane Darton Barnsley South Yorkshire S75 5DH two star good service 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: Stephanie West Date: 1 4 0 4 2 0 1 0 Information about the care home Name of care home: Address: Manor Court 31 Churchfield Lane Darton Barnsley South Yorkshire S75 5DH 01226382321 01226381299 manorcourt@schealthcare.co.uk www.schealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Darren Saunders Type of registration: Number of places registered: Conditions of registration: Category(ies) : Southern Cross Care Centres Limited care home 32 Number of places (if applicable): Under 65 Over 65 0 22 dementia old age, not falling within any other category Conditions of registration: 10 0 The maximum number of service users who can be accommodated is: 32 The registered person may provide the following category of service: 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 - Code OP, maximum number of places: 22 Dementia - Code DE, maximum number of places: 10 Date of last inspection Care Homes for Older People Page 2 of 11 Brief description of the care home Manor Court provides residential care for older people; the home has 32 beds. It is in the village of Darton with easy access to shops, post office, church, local village club and health centre and it is on the main bus route. The home accommodates people on two floors and there is a passenger lift. Manor Court has 28 single bedrooms, 7 of which are en suite and 2 double bedrooms. The upper floor accommodates 10 people. The home has 5 lounges and 2 dining rooms. There are extensive gardens, with lawns and an enclosed area, garden furniture and a water feature. There is parking at the front of the building. Care Homes for Older People Page 3 of 11 What we found: The purpose of this visit was to look at action taken to improve medicines handling in order to address concerns identified at our previous visit and to meet with current requirements. This visit focused on medicines handling, other areas were not examined on this occasion. We looked at care documentation within the home and the medication systems that were in place. We spoke with acting manager and staff responsible for medicines handling. Overall, we found weaknesses in the home arrangements for handling peoples medicines remained to be addressed to ensure that peoples health and well-being is best protected. We looked at medicines administration and were concerned to find that staff trained in medicines administration were not on duty every night. This means that medicines cannot always be safely administered should they be requested throughout the night. Additionally, on those days all medicines including sleeping tablets were administered by day staff who should go off duty at eight, o clock at night, although staff said they stayed a bit longer. Because medicines were only administered between eight, o clock in the morning and eight, o clock at night there was also a risk that where doses of the same medicine were repeated throughout the day, they will be given too closely together. Although staff at the home were enrolled on medicines training, this did not currently include any night staff. Some medicines have special label instructions e.g. before food we spoke with staff and found that no arrangements were in place to ensure these instructions were followed. This needs to be addressed to help ensure people get most benefit from their medicines. We saw that peoples medication needs were considered when they were on short stays way from the home. However, written assessments were not completed and there was no information about how this was supported with their care plans. We were concerned that for one person staff supplied the needed medicines in a completely unlabelled medicines cassette. It is recommended that pharmacist advice is sought and discussed with the people supporting medicines administration away from the home, to help ensure medicines are supplied in the safest and best way. We compared a sample of medicines record and stocks. Most medicines were supplied in a monitored dosage system; this was used correctly helping to ensure the medicines are given as prescribed. But, we were concerned to see examples where medicines had not been given because there were none left in stock. We also saw examples were records impossibly showed that more doses had been given than had actually been taken from stock. This was particularly evident for medicines supplied in traditional boxes and bottles. Additionally, we saw two examples where a medicine prescribed when required was not listed on someones current medicines administration record. For one person the homes stock of their when required medicine had accidentally been put for disposal. This increases the risk that the medicines will not be given, if needed. Records showing the application of prescribed creams and the administration of prescribed nutritional supplements were poorly completed. This meant it was not always possible to tell whether these were being used correctly as prescribed. Records showed that one person was regularly refusing a prescribed supplement; a small supply remained in stock at the home, but it was not currently listed on their medicines administration record. There was no evidence that G.P. or healthcare professional advice had been sought to see for Care Homes for Older People Page 4 of 11 example, if there was an alternative, or if the supplement should be stopped. We looked at the handling of controlled drugs and were concerned to see that the administration of a controlled drug had not been recorded and witnessed in the controlled drugs register at the time of administration. Additionally, although recent entries showed a prescribed painkilling patch had been changed at the right time, it was applied two days late at the beginning of April. Similar concerns were noted at our previous visit. The acting manager told us that staff had been issued with copies of the homes medicines policies and that assessments of staff competency were planned to begin once staff had completed the refresher medicines training. Additionally, the acting manager explained that their written audits of medicines handling would continue. This should help to ensure that weaknesses are promptly identified and addressed. The acting manager was aware that there were problems with the home running out of prescribed medicines and said a meeting was planned with the local doctors surgeries to look at medicines ordering at 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 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 registered person must ensure that as peoples needs change, they are reassessed. To ensure peoples needs can still be met at the home. 30/04/2010 2 7 13 The registered person must make arrangements to ensure that all risk assessments have control measures in place to protect people. To protect people from unnecessary risks. 31/03/2010 3 9 13 The registered person must 31/03/2010 make arrangements to ensure that all medicines are being given as prescribed by the pharmacist label. To protect peoples health, safety and welfare. 4 9 13 The registered person must make arrangements to ensure that all staff keep accurate and timely Medication Administration Records (MAR) and Controlled Drug records. To protect peoples health, 31/03/2010 Care Homes for Older People Page 6 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 safety and welfare. 5 9 13 The registered person must 31/03/2010 make arrangements to ensure that all staff responsible for administering medication are adequately trained. To protect peoples health, safety and welfare. 6 16 22 The registered person must 30/04/2010 take action to ensure complaints are robustly investigated and then inform people of the outcomes. To protect peoples rights. 7 18 13 The registered person must ensure that people are protected from being placed at risk harm or abuse. To protect peoples health, welfare and safety. 8 27 18 The registered person must 30/06/2010 ensure that staff who are working with people with dementia care needs must be offered training on how to meet their complex needs. This will better protect peoples welfare. 9 27 18 The registered person must 30/04/2010 ensure that staffing levels are adequate to meet peoples assessed needs. (Previous requirement 20/04/08, not met. This requirement has been carried Page 7 of 11 30/04/2010 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 forward with a short timescale and if not met enforcement action will be taken). To ensure peoples safety. 10 29 19 The registered person must 30/04/2010 ensure that no staff are working at the home without an enhanced CRB check, a record of this must be kept and made available for inspection. To ensure that people are protected. 11 31 9 The registered person must ensure that a manager is appointed and applies to register with CQC. To ensure the service is managed by an appropriately skilled and experienced person. 12 33 26 The registered person must 30/04/2010 ensure Regulation 26 reports are completed on a regular monthly basis and a copy is then sent in to CQC for the foreseeable future. To ensure the service is adequately monitored for the benefit of people who live in the home. 13 37 17 The registered person must ensure records required by the regulations for the protection of service users 30/04/2010 30/06/2010 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 are maintained up to date and accurate. This includes medication, complaints and staff recruitment records. To protect people from risk. 14 38 13 The registered person must 31/05/2010 ensure adequate numbers of staff are on duty at all times with up to date first aid training. To protect peoples health, safety and welfare. 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 12 Medicines must be safely administered as prescribed at the right and best times. And, Sufficient stocks of medication must be maintained at the home, without overstocking to enable continuity of treatment 17/05/2010 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. 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