Inspection on 02/06/09 for Rosedene

This inspection was carried out on 2nd June 2009.

CQC found this care home to be providing an Poor 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rosedene 14/01/10

Rosedene 20/10/09

Rosedene 16/07/09

Rosedene 28/01/09

Rosedene 12/02/08

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Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Random inspection report Care homes for adults (18-65 years) Name: Address: Rosedene 128 Franche Road Kidderminster DY11 5BE zero star poor service 04/02/2009 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: Debra Lewis Date: 0 2 0 6 2 0 0 9 Information about the care home Name of care home: Address: Rosedene 128 Franche Road Kidderminster DY11 5BE 01562861917 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Anita Homer Golden Type of registration: Number of places registered: Conditions of registration: Category(ies) : Minster Pathways Limited care home 5 Number of places (if applicable): Under 65 Over 65 0 0 learning disability mental disorder, excluding learning disability or dementia Conditions of registration: 5 5 The maximum number of service users to be accommodated is 5. 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: Mental disorder, excluding learning disability or dementia - Code MD; Learning disability - Code LD. Date of last inspection Brief description of the care home Rosedene is a care home providing personal care for up to 5 people, male and female, with a learning disability, a mental health need, or a combination of both needs. It is an ordinary house in a residential road in Kidderminster. Within the home there are Care Homes for Adults (18-65 years) Page 2 of 12 0 4 0 2 2 0 0 9 Brief description of the care home ensuite bedrooms for 5 people, 2 with their own living area as well. There is a shared kitchen, dining area and living room. The house is no-smoking, but there is a covered area in the garden for some people who do smoke. There are facilities such as shops and pubs nearby, and bus services into central Kidderminster. The home is owned by Minster Pathways Limited. The responsible individual for Minster Pathways Ltd is Mr Colin Farebrother. Ms Anita Homer-Golden has been the registered manager of the home since December 2008. Before this she was the acting manager for over a year. Care Homes for Adults (18-65 years) Page 3 of 12 What we found: This inspection took place to check on what the service had done to meet 9 legal requirements issued at its previous inspection, which was in January and February 2009. After that inspection the provider gave us an improvement plan in April 2009 which indicated that all required work had been done, or was being done. This inspection took place in June and was carried out by two Care Quality Commission inspectors, one of whom was a pharmacist inspector who came to check the homes medication arrangements. A fire officer from the local fire authority also accompanied us on the inspection. We found on this June inspection that 4 of the 9 requirements had been met:- The requirement regarding medication instructions had been met. The home had made contact with an environmental health officer and had recorded his professional advice on how to manage a specific hygiene risk. The fire officer found that the homes fire precautions were now satisfactory, apart from some recording issues which he advised them to amend. The homes gas appliances had been serviced. We found that 4 requirements had been partially met but it was not possible to see the evidence to show they had been fully met:Care plans were being updated and we saw some which had been changed. Others we asked to see were not present in the home as a senior manager had taken them to update them. This should have been completed already and plans for care should always be available to staff in the home. Some staff training had taken place, including training in first aid, fire safety, food hygiene and infection control. Other training had not yet been done or arranged. This included mental health training and learning disability training. The manager said that the quality questionnaires had been returned and were now with a senior manager who was going to compile a report and action plan. This was not yet available. We inspected the homes arrangements for ensuring staff are aware of the correct practices for preventing or reporting suspected abuse. The homes policy and guidelines, about safeguarding the people living in the home from abuse, had been updated. No staff except the manager had had training in safeguarding adults since the last inspection. This had been required to be done originally by April 2008. We found that training had been booked for May 2009 but no staff had attended it. The manager said that all the staff had gone to the wrong venue, although the venue was clearly stated on the booking letter. There was no training indicated on the staff rota for that day. Since then some training had been booked but only for 2 staff per month and not until the autumn of 2009. This indicates a worrying lack of urgency and commitment to such a vital training need. We found that 1 requirement had not been met:We also inspected the homes records of checks that they do on staff before the staff Care Homes for Adults (18-65 years) Page 4 of 12 start work in the home, to reduce the risks of allowing unsuitable people to work there. These include criminal record checks. We found that 3 staff had been working in the home, and the manager did not have any records of their recruitment checks having been done. She said they were from a Domiciliary Care Agency which is owned by the Minster Care company. We have previously made the manager aware that she must have records of all staff, including those from staff agencies. She did have evidence of recruitment checks for some other agency staff, but not for these three. The pharmacist inspector visited the home on 2nd June 2009 to check the management and control of medicines within the service. We found some areas that needed to be addressed in order to ensure that the health and wellbeing of the people who live in the service were safeguarded. Feedback was given to the manager who gave positive assurance that the points raised would be dealt with straight away. We were informed that staff had undertaken medication training provided by the Company. We saw one member of staffs certificate for Medication Handling Systems dated 21/3/09 and signed by the manager. We were also informed that staff were currently undertaking a medication course at Wolverhampton University on Managing and Safe Handling of Medicines. This was assessed monthly by an assessor. This means that staff who administer medication have received training and been assessed as competent to handle medication. We saw medication stored in secure, locked cabinets, however they were not located in the main house. Although the medication was secure there was an increased risk of transporting medication outside in poor weather and also the inconvenience for people to have to leave the main house and go to another building to receive their medication. This issue was discussed with the manager who agreed to arrange for a dedicated medication trolley to be located in the main house. We saw medication, which requires special storage arrangements under the Misuse of Drugs (Safe Custody) Regulations 1973, was not stored according to legal requirements.The manager informed us that the storage arrangement in place had been agreed by an Area Manager for the company. We saw a copy of the medication policy, which stated that these drugs must be stored in a cupboard that conforms to the regulations, which meant that the service was not following their own procedure. The manager informed us that correct and suitable medication storage would be obtained to ensure legal requirements were met. We saw a list of four staff signatures,which helped to identify who had administered medication. However, the list was not complete and not all staff had signed the list which meant that it was not always possible to identify which member of staff was involved in the administration of medication. We looked at all of the available medication administration record charts. Overall the staff were signing for the administration of medication or documenting a code with a reason why medication was not administered. We saw records for the receipt of medication documented onto the medication record charts. We checked that medication was being correctly administered. We looked at records for receipt and administration and counted medication available within the service. We found that the majority of the medication was being administered according to a doctors instructions. It was not always possible to undertake a full check because some medication in boxes or bottles did not have a date Care Homes for Adults (18-65 years) Page 5 of 12 of opening recorded so we could not complete a full audit. For example, one person was prescribed a liquid medicine which was to be given when needed. There was no record of a quantity available in the home. We found a total of 5 bottles of the medicine stored in a cupboard, which had not been documented. One bottle had been opened and used but there was no date of opening recorded. This means that it was not possible to be sure if the medication had been given as prescribed due to the lack of a complete audit trail. We saw that one person sometimes went out on social leave at lunchtime, which was documented onto their medication chart. We asked the manager how the lunchtime medication was administered. We were informed that the medication was placed in a plastic envelope and given to whoever was responsible for caring for the person. We were concerned that medication was removed and placed into an unlabelled bag, which increases the risk of a medication error. There was no written procedure for staff to follow to ensure that medication was handled safely. We discussed safe systems of managing medication when a person leaves the premises and the manager agreed to change the current unsafe practice. We saw that some people were prescribed medicine to help control their behaviour, which was to be given on a when required basis.We saw a procedure for staff to follow to ensure that the medication was given according to a behaviour management plan. We checked the medication and healthcare records for one person who had been administered one tablet for behaviour management in February 2009. We saw the records in the Daily Report which stated see ABC chart PRN administered. We were informed by the manager that an ABC chart was a written record explaining what happened before and after an incident. We asked to see the ABC charts for the person for that date but these were not available. There was therefore no written record available to show why the tablet had been administered. This means that a medication for behaviour control had been administered but there was no written documentation available to explain why it had been administered to ensure the safety of the person. 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 Adults (18-65 years) Page 6 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 6 15 Regulation 15. You must 31/03/2009 keep plans of care needed by each person living in the home, which reflect their current needs and personal preferences, including any restrictions on their choice and freedom. This will enable people living in the home to get the support they need and want. 2 35 18(1)(c) All staff in the home must 30/06/2008 receive the training they need for their work. This includes (but is not limited to) mental health, food hygiene, safeguarding adults, and infection control. This is to ensure that the people living in the home receive a consistent good quality of care. 3 35 18 Regulation 18(1)(c). All staff 31/03/2009 in the home must receive the training they need for their work. This includes (but is not limited to) mental health, food hygiene, safeguarding adults, and infection control. This is to ensure that the Care Homes for Adults (18-65 years) Page 7 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 people living in the home receive a consistent good quality of care. 4 39 24 Regulation 24(1). The 31/03/2009 registered provider must establish an effective Quality Assurance system. This is in order to show how the provider is responding to feedabck from the people who live in the home and from the Commission and other interested parties. Care Homes for Adults (18-65 years) Page 8 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 1 24 23 Regulation 23(2)(b). The office must be made secure. This is to ensure that medication and confidential records belonging to people living in the home are kept securely. 03/06/2009 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 Regulation 13(2). The 03/07/2009 service must make arrangements to ensure that all medication is administered as directed by the prescriber to the person it was prescribed, labelled and supplied for. These arrangements must also include any person who leaves the home on social leave. This is to ensure that people receive the medication they need in a safe way. 2 20 13 Regulation 13(2). The 03/07/2009 service must make arrangements to ensure that medication administration records are accurately maintained and that reasons for the administration of any Page 9 of 12 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 when required medication are clearly explained on each record. This is to ensure that people receive the medication they need in a safe way. 3 20 13 Regulation 13(2). The 03/07/2009 service must make arrangements to ensure that records are kept of all medicines available in the home including receipt, administration and disposal. This is to ensure that people receive the medication they need in a safe way. 4 20 13 Regulation 13(2). The 03/07/2009 service must make arrangements to ensure that controlled drugs are stored securely in accordance with the requirements of the Misuse of Drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations 1973 and in accordance with the guidelines from the Royal Pharmaceutical Society of Great Britain. This is to ensure that people receive the medication they need in a safe way. 5 34 19 Regulation 19(4), schedule 03/07/2009 2. When you have staff in the home who are employed by an agency, you must obtain written confirmation from the agency that they Page 10 of 12 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 have obtained the necessary information and documents specified in schedule 2, and that they are satisfied on reasonable grounds that the references are authentic. This is to reduce the risk of employing unsuitable staff in the home. 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 The service would benefit from the storage of medication being located within the main building to ensure safe administration. The service should ensure that there is an up to date signature and initial list of staff who administer medication to people who live in the service. You should ensure that you have done all that is necessary to prevent people living in the home from being harmed or abused, or being at risk of harm or abuse, and that all staff have the necessary knowledge and understanding of their role in this. 2 20 3 23 Care Homes for Adults (18-65 years) 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 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. 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