Random inspection report
Care homes for adults (18-65 years)
Name: Address: Pembroke Lodge Pembroke Lodge South Newton Salisbury Wiltshire SP2 0QD 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: David Jones Date: 0 8 1 2 2 0 0 9 Information about the care home
Name of care home: Address: Pembroke Lodge Pembroke Lodge South Newton Salisbury Wiltshire SP2 0QD 01722742066 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Glenside Manor Healthcare Services Ltd care home 14 Number of places (if applicable): Under 65 Over 65 0 physical disability Conditions of registration: 14 The staffing levels set out in the Notice of Decision dated 18 November 2002 must be met at all times Date of last inspection Brief description of the care home Pembroke Lodge is a long-stay nursing unit for younger adults with acquired brain injury. The building was purpose built for the client group. All bedrooms and living facilities are on the ground floor, with wide corridors.The bedrooms are single all with an en-suite facility providing a good standard of accommodation. The registered manager is Sarah Weston; she leads a team of nursing staff, physiotherapists, occupational therapists and care assistants provide care and support to the residents. Pembroke Lodge is one of seven registered care homes and a private hospital on one campus which are owned by Glenside Manor Health Services Ltd. Mr Andrew Norman is
Care Homes for Adults (18-65 years) Page 2 of 13 Brief description of the care home the nominated responsible individual. Glenside Manor Health Services are situated in the village of South Newton, on the A36, five miles north west of Salisbury. Care Homes for Adults (18-65 years) Page 3 of 13 What we found:
At this random inspection one of our (the Care Quality Commission) pharmacist inspectors specifically examined some of the arrangements for the handling of medicines. The home had kept us informed about two problems with medicines earlier in the year and the action taken to deal with this. Our inspection was to check that there were still safe arrangements in place for administering and handling medicines. We looked at some stocks and storage arrangements for medicines and various records about medicines. We spoke to the manager and two registered nurses. We visited some bedrooms and spoke to one person who was in his bedroom. We gave feedback at the end of the inspection to the manager. The inspection took place during a four hour period on a Tuesday morning. We thank the staff for their assistance during our visit. Registered nurses were responsible for administering and managing the arrangements for medicines. We were told that the competence of the nurses was assessed when they first started. One nurse had recently attended medicine refresher training but there was no routine medicine training to help keep all relevant staff up to date. A doctor from a local surgery visited the home regularly and arrangements were in place for people to see consultants and specialists as needed. Nobody living in this home was able to self administer their medicines so they were therefore totally dependent on the staff for this part of their care. This was covered in care plans we looked at. During the time of the inspection we saw that nurses administered the medicines needed promptly. Two medicine trolleys were available to keep the packs of medicines but during the inspection we saw these were left in the storage rooms. We discussed with the manager about safe practices for administering medicines so that the labelled medicine containers, the medicine administration chart and person receiving the medicines are all in the same place when the doses are administered. This allows a three way check and helps to reduce risks of errors. A routine such as this may have help to avoid problems the home reported to us earlier in the year. We noted that 6am was the time printed on the medicine charts for the morning doses. We were concerned if people were being woken up early just for their medicines but we were told that many people have their medicines via an enteral feeding tube so would not need to be woken. There are some advantages in giving medicines early as there is a better spread of doses throughout the day and there can be a more appropriate interval before the lunch doses. We also had some concern that nurses who had been on duty all night were responsible for administering many of the morning medicines at the end of their shift. There are often the greatest number of medicines to administer in the morning and it may not be considered good practice for staff who have been on duty all night to be responsible for all of this. If some of the medicines are in fact given later then this needs to be reflected on chart with the correct times printed. There were arrangements for keeping records about medicines received, administered and leaving the home or disposed of (as no longer needed) for each person. Accurate, clear and complete records about medicines are very important in a care home so that people are not at risk from mistakes with their medicines because of poor records and so that there is a full account of the medicines the home is responsible for on behalf of the
Care Homes for Adults (18-65 years) Page 4 of 13 people living here. Medicines were provided from a local doctors surgery (a recent change). The surgery provided printed medicine administration charts each month to help with keeping the detailed records needed to help make sure people living in the home receive their medicines safely. The way in which the dates were identified on the charts could be confusing. Many people living here can only have their medicines administered by enteral feeding tubes but this direction was often not included on the medicine charts. We looked through a sample of the medicine records and found that these were generally up to date and indicated people were receiving their medicines as prescribed. Care plans often contained information to guide staff about the use of medicines with a direction to use when required but we did see examples where we could not find any guidance. In other cases more specific information would be helpful such as the dose to use, frequency of use or interval between repeat doses and maximum dose each day. General terms such as creams or bladder washout were sometimes used without specifying what. Some records needed to state exactly what amount of medicine was administered where the direction was for a variable dose (one or two tablets for example). Other records we saw did include this information. Where nurses handwrote medicine charts or made changes these were not always signed, dated and checked by a second nurse to help reduce risks of including wrong information. Records of various prescribed treatments applied topically such as creams, ointments or lotions were often not kept very well so it was not always possible to know if such treatments had been used. Some care plans about the use of barrier or emollient creams could be clearer about when these should be used particularly as care staff often applied these. We saw there were suitable arrangements for particular medicines needed for the care of people treated for diabetes and another person treated with an anticoagulant. There were generally safe arrangements for storing medicines but we pointed out some points to consider for improvement. Medicines that are swallowed were kept together with those that are applied externally. Some sterile bladder washouts and dressings were kept in a cupboard under a sink (so with a waste pipe inside) along with cleaning materials. There was a separate medicines fridge and temperature records showed this was at the right temperature to safely store medicines. The insulin injection on the medicine trolley needed an opening date as this can only be stored for a limited period at room temperature. Liquid medicines and eye drops on the trolleys had opening dates so stock could be rotated properly. The packs of tablets and capsules did not have opening dates so audit checks to know what medicines were in stock or that doses were given correctly were not possible. Some in use containers of creams and ointments did not always have opening dates written on them or had been opened for a long time. These should be replaced regularly to prevent risks of cross infection. A pharmacist would be able to advise about these shelf life issues. Bottles of enteral feeds were kept in bathroom areas in bedrooms so we asked the manager to consider if there was any other more suitable storage area. Some people needed oxygen for which concentrator machines and cylinders were in use with warning notices displayed. Some cylinders were freestanding and not secured to prevent falling over as they should be. Separate storage was provided for controlled drugs but this was not fixed to a solid wall as required by the Misuse of Drugs (Safe Custody) Regulations 1973. There is more information about this on our website (www.cqc.org.uk). There was a separate record
Care Homes for Adults (18-65 years) Page 5 of 13 book kept for controlled drugs and two nurses signed to witness when the medicines were administered. There were no regular recorded checks of these medicines in the record book as is good practice. We pointed out some discrepancies with dates recorded for application of patches that should have been every seven days. In one case the manager checked the medicine administration chart which showed a different (but the expected) date. We cannot be sure when the medicine was given where there is such a discrepancy between records. We also found on pages 114 and 116 stock balances of medicines were recorded from August 2008 but these were not in the cupboard nor were they included on the medicine disposal sheet so at the time of the inspection these could not be accounted for. The manager told us she does audit medicine arrangements but there were no records about this. We were shown a form for a medicine audit that the director of nursing is intending to introduce. If this system had been in place it should have picked up the issues we identified at this inspection. The medicine reference book was the September 2008 edition. There was a detailed policy about the management of medicines that was available to staff so that they were aware of how the company managed medicine arrangements. This was prepared and reviewed in 2005 so was not completely up to date. What the care home does well: What they could do better:
Review practices when nurses administer medicines to make sure that accepted safe practices can always be followed. Review the arrangements for the administration of medicines at 6am in the morning to make sure these are safe and do not involve waking people living in the home too early. Nurses must always record actual doses administered where the directions indicate a variable dose (such as one or two tablets). When any handwritten additions or changes are made on medicine administration charts two nurses should sign and date these. Improve the arrangements to keep full records of any prescribed creams, ointments or lotions applied to the skin. Make sure any care plans for using these topical medicines are
Care Homes for Adults (18-65 years) Page 6 of 13 clear and contain sufficient guidance for staff about the intended treatment. Make the dates clearer on the medicine administration charts to help reduce risk of giving medicines on the wrong day. Make sure that where medicines are given via enteral feeding tubes this direction is included on the medicine label and administration chart so there is clear authorisation from the doctor to the nurses to administer medicines in this unlicensed way. Review care plans to make sure that there is always guidance to nurses about using all medicines prescribed when required or to make sure that specific guidance is always included. Upgrade the storage arrangements for controlled drugs so that these comply with the Misuse of Drugs (Safe Custody) Regulations 1973. Make sure that records kept in the controlled medicine record book are always complete and accurate. Investigate the recorded stock balances on two pages we pointed out at this inspection but where the medicines could not be found and take appropriate action to identify exactly what has happened. Notify us of the outcome of this investigation. Introduce routine recorded checks of the controlled drugs record book and stocks. Medicines for external use should be stored separately from those that are swallowed. Medicines or sterile materials should not be stored in cupboards with waste pipes inside or where cleaning materials are kept. Write the date on all medicines when they are first used so that stock can be rotated properly and proper audit checks can be made. Consider if there are more suitable storage places for the containers of enteral feeds. Secure freestanding oxygen cylinders to prevent them from falling over. Introduce regular audits of arrangements for medicines. Provide regular medicines refresher training for nurses. Review and update the policy about the management of medicines. Obtain the September 2009 edition of the British National Formulary so that staff have access to a recent reference about medicines. Please note, outstanding statutory requirements 1 to 3 listed below were not followed up at this specialist inspection of medicine arrangements so are still listed. These will be checked as properly actioned at a future inspection. 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 7 of 13 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 18 13(1)(b) All staff must conform to company policy on record keeping, so that staff have access throughout the 24 hour period to relevant information from the multiprofessional team. Not inspected at random inspection on 8th December 2009 but will be checked as properly actioned at a future inspection. 30/11/2007 2 30 13(3) When using non-slip mats in communal bathrooms, systems must be in place to ensure that they do not present a risk of cross infection. Not inspected at random inspection on 8th December 2009 but will be checked as properly actioned at a future inspection. 31/12/2007 3 42 14(a)(c) Where restraints such as 31/12/2007 safety rails or lap belts are used, a full written assessment of the service users need for such equipment and suitability for the individual service user,
Page 8 of 13 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 must be undertaken. Such assessments must be reviewed on a regular basis. Not inspected at random inspection on 8th December 2009 but will be checked as properly actioned at a future inspection. Care Homes for Adults (18-65 years) Page 9 of 13 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 Secure freestanding oxygen cylinders to prevent them from falling over. This is to prevent risk of injury and damage to the cylinder that would make it dangerous to use. 31/01/2010 2 20 13 Upgrade controlled drug storage arrangements so that the provisions of the Misuse of Drugs (Safe Custody) Regulations 1973 are complied with. This is to make sure of safe storage of these medicines and to comply with the law. 31/03/2010 3 20 13 Always keep accurate, clear 31/01/2010 and complete records about any medicines administered to people who live in the home. (This particularly refers to the shortfalls identified in the report about topical creams, ointments and lotions and recording the actual dose administered where a variable dose is
Page 10 of 13 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 prescribed.) This is to help make sure all medicines are accounted for, that people receive their prescribed medicnes correctly and are not at risk of mistakes because of poor recording arrangements. 4 20 13 Always keep accurate and 31/01/2010 complete records in the controlled drug record book. Investigate the stock balance anomalies identified at this inspection and take appropriate action to resolve these. Notify the Care Quality Commission about the outcome. This is to help make sure that all these medicines are properly accounted for and people have received the correct doses. 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 Medicines for external use should be stored separately from those that are swallowed. Medicines or sterile materials should not be stored in cupboards with waste pipes inside or where cleaning materials are kept. Introduce regular recorded checks of the controlled drugs record book and stocks. This is to make sure that these medicines can always be accounted for and any discrepancies are quickly identified and dealt with. 2 20 Care Homes for Adults (18-65 years) Page 11 of 13 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 3 20 Make sure the dates are clear on the medicine administration charts to help reduce risk of giving medicines on the wrong day. Make sure that handwritten entries on medicine charts are signed and dated by the nurse writing this with a second nurse checking and signing as correct. Make arrangements to write the date on containers of any medicines when they are first opened to use. This is to help with good stock rotation in accordance with the manufacturers or good practice directions and to enable audit checks that medicines are being used correctly and the right quantities remain in stock. Consider the arrangements for the administration of medicines to be sure that the 6am medicines are not waking people in the home too early, that it is safe for nurses to be administering many of the morning medicines at the end of their night shift and that the procedure followed when medicines are administered allows full checks of the medicines and records in the presence of the person receiving the doses. Introduce regular audits of medicine arrangements with appropriate actions taken following each audit to improve on any shortfalls and risks found. 4 20 5 20 6 20 7 20 Care Homes for Adults (18-65 years) Page 12 of 13 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 13 of 13 - 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!
