Random inspection report
Care homes for adults (18-65 years)
Name: Address: Millwater 164-168 Waterloo Road Hay Mills Yardley Birmingham B25 8LD one star adequate service 02/12/2009 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: Brian Brown Date: 0 3 0 2 2 0 1 0 Information about the care home
Name of care home: Address: Millwater 164-168 Waterloo Road Hay Mills Yardley Birmingham B25 8LD 01217063707 01217655536 Telephone number: Fax number: Email address: Provider web address: www.schealthcare.co.uk Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : West Regent Ltd care home 18 Number of places (if applicable): Under 65 Over 65 0 learning disability Conditions of registration: 18 The maximum number of service users who can be accommodated is 18. 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: Learning Disability - Code LD, of the following age range 18 and 65 years (maximum number of places 18). Date of last inspection Brief description of the care home Millwater Care Home has been registered to provide a learning disability service for up to 18 younger adults. The home is separated into three units Swan, Dove and Wren. Generally people spend their time in the unit in which they live but do from time to time visit people living in other units. Accommodation is in single rooms with en-suite facilities. There is a communal lounge and dining area in each unit and in Swan unit
Care Homes for Adults (18-65 years) Page 2 of 10 0 2 1 2 2 0 0 9 Brief description of the care home there is an activity room. In Swan unit there is a commercial kitchen and in Dove and Wren units there are small domestic type kitchens. There is a separate laundry in Swan unit. Facilities for laundry are available in the kitchens in Dove and Wren units. The grounds are fully enclosed with access from inside the building only. There is a small area outside the main entrance for off road parking. The home is situated close to major bus routes in and out of Birmingham City Centre.Local shops and amenities are within walking distance and the Swan Shopping Centre is approximately one mile away. The service users guide stated that the last inspection report is available on request from the Manager or in the homes reception area. The service users guide stated that the fees charged depend on individual assessment. These include accommodation, 24 hour staffing, all meals and beverages, laundry except dry cleaning and in - house activities. This information was current at the time of the inspection and the reader may wish to contact the care service for updated information. Care Homes for Adults (18-65 years) Page 3 of 10 What we found:
This inspection was carried out by two pharmacist inspectors to look at compliance with requirements made at the inspection 02 December 2009 We spent two hours twenty minutes at the service. We looked at Medication Administration Record (MAR) charts, care plans and other documentation for four people. We spoke to the operations manager and one other member of staff. At the end of the inspection feedback was given to the operations manager. We found that all medicines were stored in locked trolleys and medicine cupboards. We found one medicine, that the manufacturer states must be stored below 15C was in storage at room temperature. The room temperature had been recorded as being between 19C and 26C from 30 January 2010. This medicine was dispensed on 2 January 2010, we found no evidence that steps had been taken to confirm if this medicine was still suitable for use. We found for one person, that one of their medicines had been recorded as administered four times a day, for four days, when it had been prescribed for administration once a day. We found no record of action taken to inform the prescriber of this or discussions with members of staff who had carried out these administrations. For another one of their medicines there had been no record of administration for ten days, with no explanation for the non-administration recorded on the MAR chart or in the care plan and also no indication that the prescriber had been informed. We found for another person that one of their medicines had not been administered for three weeks, the MAR chart being annotated as not required, but no reason had been recorded in the care plan or other documentation for this decision. We found that one person had not received a medicine that had been prescribed on 26 January 2010. Staff interviewed were unaware that the person had not been receiving this medication for the previous eight days,no records for non-administration had been made on the MAR chart and we found that the change in medication had not been noted in the care plan, communication book or the staff handover notes. We found no evidence that the omission had been noted or that steps had been taken to obtain the medicine. We found that the use of a number of medicines prescribed to be administered as when required were either not supported by protocols, or the protocols lacked sufficient information for the staff to follow. We found that the home was carrying out a daily check of medicine stock and administration records. However we could find no information about the actions taken when discrepancies had been found. This means that people cannot be assured that if errors occur, they will be addressed appropriately. What the care home does well:
We found that the service had made arrangements to store all medicines securely. This means that the access to medicines is restricted to authorised people only.
Care Homes for Adults (18-65 years) Page 4 of 10 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 Adults (18-65 years) Page 5 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 6 12 Each person must have a care plan that reflects their needs and preferences. So that staff know how to support individuals to meet their needs and achieve their goals. 31/03/2010 2 9 13 Risk assessments must detail 31/03/2010 how people are to be supported. To minimise the risks to peoples safety and well being. 3 18 13 Guidelines must clearly state 31/01/2010 how staff are to support individuals to move. So reducing the risks of the individual and staff getting hurt. 4 19 12 Each person must have a plan that states how their current health needs are to be met. So that staff know how to support them. 31/03/2010 5 23 13 All staff must receive training 31/05/2010 in safeguarding. To ensure they know how to Care Homes for Adults (18-65 years) Page 6 of 10 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 safeguard the people living there from abuse. 6 35 12 Staff must have the training they need. So they know how to support the people living there to meet their needs. 7 37 8 A manager must be recruited 31/05/2010 who has the required skills and qualities. So that the people living there benefit from a well run home. 31/05/2010 Care Homes for Adults (18-65 years) 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 20 13 (2) Arrangements must be 17/02/2010 made to administer medicines as prescribed. Also arrangements must be made to contact the prescriber if these directions are not followed This is to make sure that people receive their medicines as prescribed 2 20 13 (2) Arrangements must be made to have information available to people working at the home about how people are to be supported to receive medicines prescribed to be administered when required This is to make sure that these medicines are to be administered both safely and appropriately. 17/02/2010 3 20 13 (2) Arrangements must be in 17/02/2010 place to store medicines in accordance with the manufacturers directions
Page 8 of 10 Care Homes for Adults (18-65 years) 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 This is to make sure that medicines are effective when used 4 20 12 (1) Arrangemente must be 17/02/2010 made to obtain medicines, so that they can be administered as prescribed. This is to make sure that people receive their medicines as prescribed 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 20 It is recommended that the audit system for medicines in the home be reviewed, to promote the safe management of medicines within the home. Care Homes for Adults (18-65 years) 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 Adults (18-65 years) 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 Adults (18-65 years) 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!
