Inspection on 22/06/10 for Princess Lodge Care Home

This inspection was carried out on 22nd June 2010.

CQC found this care home to be providing an Adequate 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Princess Lodge Care Home 11/02/10

Extracts from inspection reports are licensed from CQC, this page was updated on 04/09/2010.

Random inspection report Care homes for older people Name: Address: Princess Lodge Care Home 11 High Street Tipton West Midlands DY4 9HU one star adequate service 11/02/2010 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: Karen Thompson Date: 2 2 0 6 2 0 1 0 Information about the care home Name of care home: Address: Princess Lodge Care Home 11 High Street Tipton West Midlands DY4 9HU 01215571176 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Frank Thomas Josef Brown Type of registration: Number of places registered: Conditions of registration: Category(ies) : Princess Lodge LTD care home 25 Number of places (if applicable): Under 65 Over 65 0 25 dementia old age, not falling within any other category Conditions of registration: 5 0 The maximum number of service users who can be accommodated is: 25 The registered person may provide the following category of service only: Care Home with Nursing - Code N 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 25 Dementia - Code DE 5 Date of last inspection Brief description of the care home Princess Lodge comprises of a traditional property that has a large extension (exceeding the size of the orginal property) . It is located on a fairly busy main road Care Homes for Older People Page 2 of 12 1 1 0 2 2 0 1 0 Brief description of the care home leading into Tipton. The home is in close proximity to local shops, public houses, a church and a main bus route. Princess Lodge is registered to provide Nursing care to those within the category of old age. The home has recently undergone major renovation, refurbishment and redecoration. The home offers eighteen single bedrooms of which the majority have ensuite facilities. The fees were not identified at the time of the visit as no Service User Guide was available. The Reader should contract the service directly for fees information. Care Homes for Older People Page 3 of 12 What we found: We visited the home to assess its compliance with requirements made from the key inspection visit of February 2010. We had also had concerns raised with us prior to the visit about the number of staff available to meet the needs of people living in the home. We found the home had not met five of the six requirements made. This means the home is in breach of the Care Homes Regulations 2001. We have issued a warning letter for four of the unmet requirements and will continue to monitor the homes progress in meeting these. We have issued a Statutory Requirement Notice for a requirement made in relation to the safety of medication. A Statutory Requirement Notice is the first stage of the enforcement process we take to ensure the health and well being of people living in the home. We have also liaised with other agencies to protect the well being of people living in the home. We looked at the arrangements in place for medication management. Medication is stored in a trolley in a locked medication room. Copies of the original prescriptions were not available to check the right medication had been received from the chemist. We were unable to audit the medications due to balances from the previous cycles not being included on the current Medication Administration Record (MAR) or the quantities of medication received into the home for that cycle being included on the MAR chart. A requirement was made at the last inspection to ensure that medication was stored at the temperature compliant with the drug manufacturers instructions. Temperature recordings showed that the room was above this at times. This meant that medication stored within the room had had its stability compromised, which may affect the well being of people taking the medication. We were advised by the owner that they were in the process of ensuring the room had an effective air conditioning unit. The home should have sought an alternative location for the storage of medication whilst the temperatures in this room were resolved to be within the acceptable range. The home was unable to produce a thorough examination certificate for the passenger lift which was in use in the home at the time of our visit. We advised the home we would be contacting the Health and Safety Executive about this matter. The Health and Safety Executive are now working with the home to resolve this matter. We looked at the recruitment process for four new staff. We found that one member of staff had been employed and been working in the home prior to an Independent Safeguard Authority first (ISA) being obtained in April 2010. We also found that two members of staff had gaps on their employment histories and there was no evidence to suggest that these had been explored. We also found that staff have been employed in the home on an ISA first whilst awaiting a Criminal Records Bureau disclosure without a risk assessment being carried out. We will be making a new requirement in relation to this. We also found that one member of staff had supplied a reference for an employer not declared on their employment history. We are aware that despite the breach the most recent person recruited to the home had a robust recruitment procedure carried out. Staff working in the home told us they thought there were enough staff to meet people needs. We did observed for short periods though out the day the lounge to have no staff present to offer support to people living in the home. On the day of our visit the Care Manager was also working in the kitchen as there was no cook available to serve Care Homes for Older People Page 4 of 12 breakfast. Staffing levels should be kept under review in light of the number and changing needs of people living in the home. We looked at staff training records in relation to safeguarding. We found no written documentation to demonstrate that staff had received training in safeguarding procedures. We spoke to two members of staff and they confirmed that they had not received training in safeguarding. Staff spoken to however did tell us that they would either let the most senior person on shift know of any concerns or report to the manager 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 12 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 9 13 The home must purchase a 16/04/2010 room thermometer and record daily the temperature of the medication and take appropriate action if the room temperature does not comply with the medication product licence. All medication must be stored in accordance with their product licence. 2 18 13 The home must ensure that staff are trained and knowledgeable about the safeguarding procedure. To promote and protect the wellbeing and safety of people living in the home. 30/04/2010 3 29 19 The recruitment process 30/04/2010 must look at the previous employment history and any queries or gaps must be explored. To demonstrate a robust recruitment procedure has taken place and that people living in the home have their health and well being protected. 4 29 19 The home must ensure that it has obtained two 30/04/2010 Care Homes for Older People Page 6 of 12 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 references for staff prior to commencing work in the home. To ensure the safety of people living in the home is promoted and protected 5 38 23 The passenger lift should 30/04/2010 have a thorough examination carried out every six months and records must be available to demonstrate this. To ensure the lift is working correctly and does not place anyone at risk. Care Homes for Older People Page 7 of 12 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 13 The quantity of all medicines 16/07/2010 received and any balances carried over from the previous cycle must be recorded to enable audits to take place. This will demonstrate that medication is being administered as prescribed. 2 29 19 If staff commence work in 16/07/2010 the home on an Independent Safeguarding Authority first a written risk assessment must be completed. To demonstrate any risks have been considered and the appropriate action has been taken to reduce them. 3 29 19 The Recruitment process must include all documents required by Schedule 2 of the Care Homes Regulations 2001. To ensure that a robust recruitment process is completed and people living 16/07/2010 Care Homes for Older People Page 8 of 12 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 at the home are protected. 4 33 24 The home must submit an 31/07/2010 improvement plan that clearly details the action the home will take to address the shortfall identified in the report. This will show the action the home will take in order to improve the service for people living there. 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 1 A Statement of Purpose and Service User Guide must be available to people living in the home and prospective persons wishing to live in the home. They must contain all the relevant information and be in a formate that is accessible to them, so they can make an informed choice. ( Recommendation made February 2010, not looked at during this visit) Trained staff working at the home should re-familiarise themselves with the Nursing and Midwifery Council document Record keeping:Guidance for nurses and midwives 2009. ( Recommendation made February 2010, not looked at during this visit) Care plans should be in place within twenty four hours of arrival to the home so that staff have clear instructions as to what is required to meet someones needs and monitoring and evaluation of the condition can be documented. ( Recommendation made February 2010, not looked at during this visit) Risk assessments should be drawn up in a timely manner and should include falls, nutrition and continence, they should be reviewed regularly and when changes have Page 9 of 12 2 7 3 7 4 8 Care Homes for Older People 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 occured to ensure any risk to people living at the home are appropriately managed. ( Recommendation made February 2010, not looked at during this visit) 5 9 Handwritten Medication Administration Charts should contain the signature of the staff receiving and recording the medication in the home, to ensure an accurate record. It the hme should consider implementing a Homely Remedies policy and procedure so that minor ailments can be treated swifty. This must be a reflection of good practice and staff must be trained to adhere to it. ( Recommendation made February 2010, not looked at during this visit) People living at the home should be consulted about the use of the dining/lounge area for training purposes or an alternative space for training sought. ( Recommendation made February 2010, not looked at during this visit) Activities must be reviewed and base on individual needs. ( Recommendation made February 2010, not looked at during this visit) It is recommended that the home obtain a copy of the Department of Health guidance Mental Capacity Act 2005 core training set published July 2007 and staff are provided with training, so that staff are aware of their responsibliites and people rights are protected. ( Recommendation made February 2010, not looked at during this visit) The complaints procedure must be amended to contain the correct details on how to contact the Care Quality Commission. ( Recommendation made February 2010, not looked at during this visit) It is recommended that the home obtain a copy of the Department of Health Guidance Mental Capacity Act 2005 residential accomodation published 2007. ( Recommendation made February 2010, not looked at during this visit) The assisted bath on the first floor prior to use should have a lifting certificate to demonstrate it is safe for use. A risk assessment should be drawn up for the use of the laundry and any risks identified should be reduced. ( Page 10 of 12 6 9 7 10 8 12 9 14 10 16 11 18 12 13 21 26 Care Homes for Older People 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 Recommendation made February 2010, not looked at during this visit) 14 26 The home should contact the Infection Prevention and Control Team at Sandwell PCT, they will assist the hme to carry out an infection control audit. This will help identify any concerns and wasy in which they can be reduced. They are based at Kingston House, 438 High Street, West Bromwich, B70 9LD. Telephone number: 0121 612 1627 A handwashing sink for staff should be available for use in the laundry. ( Recommendation made February 2010, not looked at during this visit) A minimum of fifty percent of staff should be trained to NVQ2 or above and records/copies of certificates should be available to demonstrate this. ( Recommendation made February 2010, not looked at during this visit) The home should introduce an induction programme that meets the Common Induction Standards for staff working in the home. ( Recommendation made February 2010, not looked at during this visit) The quality assurance system must look at a number of areas within the home such as medication, views of people living there and maintenance issues any matter arising from these must be swiftly addressed and monitored on a regular basis to ensure and develop positive outcomes for people. 15 26 16 28 17 30 18 33 Care Homes for Older People Page 11 of 12 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 12 of 12 - 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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