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: Debby Railton Date: 0 3 0 3 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:
The pharmacist inspection lasted one and a half hours. The reason for the inspection was to check compliance with the regulations regarding medicines left at the last inspection on 3rd February 2010. Five people medicines were looked at together with their Medicine Administration Record (MAR) chart and care plans. The senior team leader was present throughout the inspection and all feedback was given to the project manager recently appointed to address the issues found at previous inspections The home now stored all medicines correctly. There was a dedicated medicine room which was temperature controlled and a locked medicines refrigerator to store medicines requiring refrigeration. All medicines were stored and transported to the people in the home in two locked medicine trolleys and any remaining surplus medicines were kept in a locked cabinet. The medicine refrigerator and room temperatures were recorded daily and were within the correct limits to safely store medicines. All controlled drugs were stored in compliance with current regulations The home saw all the prescriptions before they were dispensed and a copy was taken and used to check the medicines dispensed and received into the home. The quantity of all medicines were recorded, including any balances carried over from previous cycles. This enabled audits to take place to demonstrate whether the medicines had been administered as prescribed and records reflected practice. Audits indicated that the majority of medicines had been administered as prescribed and all reasons for non administration clearly documented. The doctor had been informed if any discrepancy was found and his instructions followed. Each persons MAR chart had a facing page which included an identifying photograph and any allergies the person may have. All people had well written protocols for staff to follow for medicines prescribed to be administered on a when required basis. This would enable staff to clearly know when and how many tablets to adminsiter if needed and the intervals between administration. The Senior team leader had a very good understanding of the clinical needs of the people she looked after and also what the medicines were for. This was commended The home had installed a quality assurance system based on observational practice and we, the commission, were assured that a handover period between team leaders was to be introduced to include a daily check of the MAR charts so any discrepancy could be immediately addressed. What the care home does well:
The medicine management had improved to a safe standard and both the two outstanding and four new requirements left at the last inspection regarding medicines had been fully met. 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 20 13 (2) Arrangements must be 17/02/2010 made to administer medicines as prescribed. Also arrangements must be made
Page 6 of 10 Care Homes for Adults (18-65 years) 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 to contact the prescriber if these directions are not followed This is to make sure that people receive their medicines as prescribed 6 20 13 (2) Arrangements must be in 17/02/2010 place to store medicines in accordance with the manufacturers directions This is to make sure that medicines are effective when used 7 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. 8 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 9 23 13 All staff must receive training 31/05/2010 in safeguarding. 17/02/2010 Care Homes for Adults (18-65 years) Page 7 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 To ensure they know how to safeguard the people living there from abuse. 10 35 12 Staff must have the training they need. So they know how to support the people living there to meet their needs. 11 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 8 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 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 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. © 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 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!
