Inspection on 24/03/10 for Sunrise Operations Edgbaston Ltd (Assisted Living)

This inspection was carried out on 24th March 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 but made no statutory requirements on the home.

Other inspections for this house

Sunrise Operations Edgbaston Ltd... 27/04/10

Sunrise Operations Edgbaston Ltd... 19/01/10

Sunrise Operations Edgbaston Ltd... 15/10/09

Sunrise Operations Edgbaston Ltd... 07/09/09

Sunrise Operations Edgbaston Ltd... 29/04/09

Sunrise Operations Edgbaston Ltd... 29/10/08

Extracts from inspection reports are licensed from CQC, this page was updated on 03/06/2010.

Random inspection report Care homes for older people Name: Address: Sunrise Operations Edgbaston Ltd (Assisted Living) 5 Church Road Edgbaston Birmingham B15 3SH one star adequate service 29/04/2009 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: 2 4 0 3 2 0 1 0 Information about the care home Name of care home: Address: Sunrise Operations Edgbaston Ltd (Assisted Living) 5 Church Road Edgbaston Birmingham B15 3SH 01214551100 01214556689 Telephone number: Fax number: Email address: Provider web address: www.sunrise-care.co.uk Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Sunrise Operations Edgbaston Limited care home 68 Number of places (if applicable): Under 65 Over 65 68 old age, not falling within any other category Conditions of registration: 0 The maximum number of service users to be accommodated is 68. 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 (OP) 68 Date of last inspection Brief description of the care home Sunrise Senior Living Edgbaston offers a purpose built care home for older people who require varied levels of support with day to day living (Assisted Living), nursing care and residential care. People can choose to live in the home for a short or long term stay. Care Homes for Older People Page 2 of 10 1 9 0 1 2 0 1 0 Brief description of the care home Sunrise Assisted Living is registered to provide assisted living care with nursing for up to 68 older people. Assisted living care is provided on the ground and first floor of the premises. The home offers spacious accommodation within bedroom suites of varying sizes and layouts. Each suite provides a bedroom, living area and en suite facilities, which has a level floor access shower or a bath. Two separate spa baths are available for communal use. The home offers a luxurious, beautifully furnished and well maintained environment for people to live in. Two passenger lifts and staircase provides access to all floors in the home. There is a large lounge, restaurant style dining room and a well maintained kitchen. A charge is made for the bedroom suite accommodation £140 - £240 per day. An additional charge is made for a care package these prices range from £19 to £66.50 per day. Each additional hour of care is charged at £19. Additional charges are made for ironing services, care staff escort, chiropody, medication administration and weekly furniture rental. Care Homes for Older People Page 3 of 10 What we found: The pharmacist inspection lasted three hours. Nine peoples medicines were looked at together with their medicine Administration Record (MAR) chart and care plans. All feedback was given to the manager at the end of the inspection. The reason for the pharmacist inspection was to check compliance with the Statutory Requirement Notice issued on 10th February 2010. Following the pharmacist inspection on 19th January 2010 requirements regarding the safe handling of medicines had not been met, so a Statutory Requirement Notice was issued, due to these serious repeated breaches of the Regulations regarding the mal-administration of medicines. The requirements had to be complied with by 25th February 2010. The home was required to 1. Make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. 2. Ensure that all medications are administered as per the prescribers instructions. 3. Put appropriate systems in place to assess people who wish to take their own medications (self medicate), to regularly carry out audits and take action when discrepancies are found. 4. Where medication regimes are changed, ensure that the instructions are carried out and a clear documented audit trail is in place to confirm that the changes have been actioned. 5. Ensure that accurate recordings are made of all medication processes and administrations. The statutory requirement notice was breached regarding points 1,2,3 and 5 following this inspection. Medicines had been recorded as administered when they had not been. Gaps were seen on the MAR chart. Staff had failed to record when they had administered a medicine or failed to record the reason for non-administration. Incorrect codes for non administration of medicines had been recorded, so it was not a true reflection of what had occurred. Two different medicines had been prescribed and dispensed to administer daily but nursing staff had recorded they administered the medicine twice a day on two occasions. The commissions audits indicated that they had not. One antibiotic had been recorded as administered four times a day and not three times a day as prescribed. Again nursing staff are failing to record exactly what occurred and the records were not a true reflection of what the nurse had done in the home. Medicines prescribed to administer on a when required basis had no supporting protocols for nursing staff to follow, to ensure that they were administered as the doctor intended. Information regarding one medicine used to control behaviour had conflicting doses Care Homes for Older People Page 4 of 10 recorded on the back and front of the MAR chart. The nursing staff failed to record accurately what had occurred on one occasion. Two 2mg diazepam tablets had been recorded as administered on the front of the MAR chart but the nurse had also recorded that only one 2mg tablet had been administered on the back. Audits indicated that the information recorded on the front was correct. This is of concern. Staff had failed to record the administration of a controlled drug on one occasion on the MAR chart but had recorded its administration in the Controlled drug register. Conversely on the following day nursing staff had recorded that they had administered the dose on the MAR chart but not the CD register. The manager had installed a quality assurance system to assess whether the records were accurate but these had failed to identify these errors seen. Concern was raised that they home was only three days into the 28 day cycle so any errors should have been minimal but there were many. The medicines for two people who self administered their own medicines were looked at. These indicated that the majority of their medicines had been administered as prescribed but incorrect checking in of two medicines for the new cycle resulted for one person, resulted in the commission being unable to demonstrate that they had taken them as prescribed. We, the commission were assured that compliance checks were undertaken if the resident allowed them to do so. The care plans varied in content. It was not possible to identify the clinical needs of one person, so the staff would not be able to fully support their needs. This was a requirement from the last two inspections and had not been met. Due to the seriousness of these errors seen a further management review was held to discuss further enforcement action. 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 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 7 15 The care plans must include information to support the service users clinical needs This is to ensure their health and welfare 15/11/2009 2 9 13 All service users must be risk 03/10/2009 assessed as able to self administer their own medication and a MAR chart written to record these prescribed medicines. Regular compliance checks must be undertaken and documented and further support offered if necessary. This is to ensure that they can handle their medication safely 3 9 13 The medicine chart must 03/10/2009 record the quantity of medicines received and the date. It must be referred to before the preparation of the service users medicines and be signed directly after the transaction and accurately record what has occurred. This is to ensure that the right medicine is administered to the right service user at the right time Care Homes for Older People 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 and at the right dose as prescribed and records must reflect practice 4 18 13 All allegations and incidences 31/05/2009 of abuse must be taken seriously by making sure that a timely and informed investigation can take place if appropriate. This will make sure that people feel confident that they are protected from the risk of abuse while living in the home. 5 27 18 Staffing levels must be 31/07/2009 reviewed to make sure that sufficient numbers are on duty at all times. This must include reviewing the times when care staff are involved in housekeeping, waitressing and laundry tasks. This will make sure that care hours for people living in the home are not depleted while staff undertake non care duties. 6 28 18 Work is needed to increase 31/07/2009 the number of care staff with a NVQ level 2 qualification or equivalent in care. This will make sure that people living in the home are cared for by competent and qualified staff. 7 37 37 Systems must be put into place to ensure that we are 29/05/2009 Care Homes for Older People 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 informed about incidents and accidents affecting the health, safety and wellbeing of people living in the home. This must include making us aware of any incidence of suspected or alleged abuse. This will help to make sure that people living in the home are protected from the risk of harm. Care Homes for Older People 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 1 9 It is advised that the quality assurance system to assess the management of medication is improved, to enable management to assess individual staff practice and also to identify medicine errors earlier. Care Homes for Older People 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 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 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!