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Inspection on 12/05/09 for The Foundation of Lady Katherine Leveson

Also see our care home review for The Foundation of Lady Katherine Leveson for more information

This inspection was carried out on 12th May 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The medicine management had improved to a safe standard. Recruitment practices had been overhauled resulting in a good system to recruit and track progress of applications. The manager, Anne Atkinson and the deputy care manger were very proactive during the inspection and keen to improve the systems further in the home and this was commended.

What the care home could do better:

New care plans have been installed. These were in their infancy and need to be fully completed with all the relevant and pertinent information for staff to be able to follow to meet the peoples` care needs.

Random inspection report Care homes for older people Name: Address: The Foundation of Lady Katherine Leveson The Foundation of Lady Katherine Leveson Temple Balsall Solihull West Midlands B93 0AL zero star poor 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: Debby Railton Date: 1 2 0 5 2 0 0 9 Information about the care home Name of care home: Address: The Foundation of Lady Katherine Leveson The Foundation of Lady Katherine Leveson Temple Balsall Solihull West Midlands B93 0AL 01564772850 01564778432 Telephone number: Fax number: Email address: Provider web address: www.leveson.org.uk Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : The Foundation of Lady Katherine Leveson care home 30 Number of places (if applicable): Under 65 Over 65 30 old age, not falling within any other category Conditions of registration: Date of last inspection Brief description of the care home 0 The Foundation of Lady Katherine Leveson was founded in 1674 to provide almshouses for women in need. It now provides sheltered and residential care accommodation for older men and women. The foundation, which is a charity, offers accommodation for 30 residential service users and 15-sheltered accommodation places. The Court of Lady Katherine Leveson is situated in Temple Balsall, lying between Knowle and Balsall Common. It is a listed building and the majority of service users live in self-contained accommodation in the Court Yard where they have views of the mature gardens and a secure and pleasant place to walk and sit. The accommodation is mixed, all have ensuite toilet facilities, and some have a bath or shower. There are a number of suites comprising of a bedroom, small lounge, kitchen and bathroom. The Court of Lady Care Homes for Older People Page 2 of 9 Brief description of the care home Katherine Leveson has a Christian ethos, and although they will consider nonChristians, it is required that the people resident are sympathetic to the Christian ethos. There is also a 14th Century Templar Church on the premises and people are invited to attend the service on Sundays and other Christian celebrations. The registered provider is referred to as the Master and is an Anglican priest. Fees vary and are dependent on the needs of individual people. Items not covered by the fees include toiletries, private treatments such as physiotherapy and chiropody, hairdressings and newspapers. The homes ranges of fees are between £447 and £519 per week. For up to date fee information the public are advised to contact the home. Care Homes for Older People Page 3 of 9 What we found: The reason for this inspection was to check compliance of two statutory requirement notices issued on 15th April 2009, one regarding poor medicine management and one regarding poor recruitment practices, both identified at the last inspection on 4th March 2009. A statutory requirement notice was issued on the 15th April 2009 regarding medication, breaching Regulation 13(2) of the care Home Regulations 2001, where many poor practices were seen resulting in the medication not being administered as prescribed. The home was required by 22nd April 2009 to: 1 make arrangements to ensure that all medication is administered as directed by the prescriber to the service user it was prescribed, labeled and supplied for 2 make arrangements to ensure that medication administration records are accurately maintained; that the reasons for non-administration of medication are recorded by the timely entry of an appropriate code on the administration record 3 arrangements are in place to ensure that prescribed medications are available to administer at all times 4 ensure that an effective system is in place to check that medication received corresponds to the instructions of the prescriber. All four requirements of the notice had been fully met. A statutory requirement notice was issued on 15th April 2009 regarding poor recruitment practices breaching Regulation 19 of the Care Home Regulations 2001. The home was required to by 22nd April 2009 to: 1 obtain in respect of all people employed at the home all the relevant information and documents as required by Regulation 19(b) and paragraphs 1-9 inclusive of Schedule 2 of the care Homes Regulations 2001 prior to them commencing employment. 2 put in place at the home to ensure that persons are not employed to work at the home until such time as you have obtained all the relevant information and documents as required by Regulation 19(b) and paragraphs 1-9 inclusive of schedule 2 of the Care Homes Regulations 2001. 3 put in place arrangements to ensure that, in cases where you are satisfied that persons can commence work at the home having received a satisfactory POVA First check, but pending receipt of a satisfactory CRB Disclosure, are subject to appropriate supervision and that they do not at anytime during such period escort users away from the care home unless accompanied by their nominated supervisor. All three requirements of the notice had been fully met. Care Homes for Older People Page 4 of 9 The manager, deputy care manager and staff had worked hard during this period resulting in all the requirements surrounding the poor practice for regulations 2,13,19 and 23 had also been fully met and this was commended. The home was working towards complying with the regulations regarding care planning. The pharmacist inspection lasted three hours. Four residents medication, medicine administration record (MAR) charts and care plans were looked at. All documentation for new recruits were also looked at together with the gas certificate that was not available at the last inspection. The deputy manager was present throughout the inspection. She had installed a good system to check all the prescriptions prior to dispensing and to check the new medication received into the home. All balances carried over from previous MAR charts and the quantities of new medicines received had been recorded enabling audits to take place to demonstrate that the medicines had been administered as prescribed and records reflected practice. The majority of medicine had been administered as the doctor intended. A few errors were seen but these had been previously identified by the deputy manager during her own internal quality assurance system Two quality assurance systems were in use. One to routinely check the medicines in the home to confirm actual balances equaled the calculated balances and one to assess individual staff practice. This had resulted in the improvement of the medicine management in the home. Two care assistants were spoken with during the inspection. The senior carers knowledge of medication was very good and the care assistant undergoing training also had a good understanding of the medicines she handled. The management had installed a good system to enable staff to quickly check what the medicines commonly prescribed in the home were for, and had also had purchased three new books about medication for reference. Residents wishing to self-administer their own medication are now risk assessed as able before they do so and offered extra support to maintain their independence. Regular compliance checks are also undertaken to ensure the residents safely take their own medication. All Controlled Drug (CD) balances were correct and the records in the CD register matched those on the MAR chart indicating good practice. All were correctly stored in the CD cabinet. New medication policies had been written and staff trained to adhere to them. An advanced training package in the safe handling of medicines, presented by an external pharmacist had been attended by the care staff that handled medication. All medication is kept in the individuals room in a locked cabinet and some new cabinets had been purchased if the old one was too small. Residents are administered their medication in their room for the majority of doses but a new system had been installed where staff transport the lunchtime medicines to the resident in a locked box. This replaced the previous high risk practice of carrying medication in open pots from the residents room to the resident wherever they were in the home. Care Homes for Older People Page 5 of 9 The care plans had improved and a new system, albeit in its infancy, had been implemented in the home. They were a lot easier to use. The staff have yet to include all the relevant details from the old care plans but this task is currently underway. All external health care professional visits are now documented and it was easy to see when a professional had visited and what the outcome was. This made to easy to track any dose changes the resident may of had. The home has totally overhauled the staff recruitment process. All staff now have a POVA check before they are given a start date and then once recruited are supernumerary to the general staff group, i.e they work under supervision until their Criminal Record Bureau disclosure has come though. All references are followed up and their identification checked against at least two different sources. The manager had introduced a new spreadsheet to track individual recruitment progress. At the last inspection one resident was found to be living in an unregistered flat in the sheltered accommodation in the home, but received personal care from the care home staff. This situation had been rectified and there was a definite distinction between those people receiving a domiciliary care package living in the sheltered accommodation and those living in the registered flats and rooms receiving personal care by the care home staff in the care home. At the last inspection it was found that the gas company had failed to issue a gas certificate to confirm both boilers in the home had had their annual gas check. This was forwarded once received after the last inspection and again inspected this time. Both boilers had passed their annual check. 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 6 of 9 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 15(2)(b)(c) 12(1)(a)(b) Care 20/04/2009 plans must be reviewed regularly and when a persons needs change. This is to ensure that people receive care appropriate to their current needs 2 7 15 (1),12(1)(a)(b)Care plans must be prepared for every care need identified. This is to ensure that people have the care, treatment and medication they need to maintain their health and wellbeing. 20/04/2009 3 8 13 (4)(c) People must have a 20/04/2009 detailed assessment for the use of bedrails. Records must be kept of checks made that bed rails remain in good order. This is to ensure that the person is not put at more risk by their use. Care Homes for Older People Page 7 of 9 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 Older People Page 8 of 9 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. 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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