This inspection was carried out on 18th January 2010.
CQC found this care home to be providing an Good 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for older people
Name: Address: Ventress Hall Care Home 22-28 Trinity Road Darlington Durham DL3 7AZ two star good service 06/01/2009 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: Janet Long Date: 1 8 0 1 2 0 1 0 Information about the care home
Name of care home: Address: Ventress Hall Care Home 22-28 Trinity Road Darlington Durham DL3 7AZ 01325488399 01325480011 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Judith Goode Type of registration: Number of places registered: Conditions of registration: Category(ies) : Southern Cross OPCO Ltd care home 106 Number of places (if applicable): Under 65 Over 65 106 0 old age, not falling within any other category physical disability Conditions of registration: 0 45 The maximum number of service users who can be accommodated is : 106 The registered person may provide thfollowing 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 maximum number of places : 106 Physical disability- Code PD, maximum number of places 45 Date of last inspection 0 6 0 1 2 0 0 9 Care Homes for Older People Page 2 of 10 Brief description of the care home Ventress Hall is a care home with nursing for up to 106 older people. It was registered by its current owners, Southern Cross OPCO Ltd., in August 2007. Ventress Hall was purpose built in 1989. It is conveniently located, close to Darlington town centre and other amenities. The home is a three-storey building with passenger lifts between floors. There is a central courtyard garden with seating, pleasant floral displays and a water feature. Care Homes for Older People Page 3 of 10 What we found:
This pharmacist inspection lasted eight hours and was carried out as a follow up to medication concerns at a random inspection in December. During this visit we examined medication policy and proceedure, the current medication administration record (MAR), and the medication ordering, storage and handling arrangements. There is a good, detailed policy in the home covering all aspects of medicines management. This means that staff have access to up to date information on legal requirements and guidance. The standard of accurate record keeping is poor; there were a number of gaps on the MAR charts. An audit of current stock and records showed that some medication had been signed for but not given. The home was currently using a running balance system to check stock but in some cases the running balance did not match the amount of medication in stock and no action had been taken. The MAR chart records for nutritional supplements and creams were incomplete. In some cases creams prescribed for application twice daily were only being signed for on the MAR charts once daily. Photographs were missing from several MAR charts on the first floor. There is inconsistency in the recording of the quantity of medication supplied and the date received. The quantity of medication from one monthly cycle to another is not recorded on the new MAR in all units. This makes it difficult to have a complete record of medication within the home and to check if medication is being administered correctly. There was incomplete handwritten entries and changes made to medication, in one instance the handwritten entry was incorrect. To make sure there is an accurate record the quantity supplied, the date of the entry, the signature of the person making the entry and a witness signature where possible should be included. Medicines are stored securely either in locked trolleys or locked cupboards. There were good records of fridge and room temperature however one storage room recorded a room temperature above 26 degrees centigrade for the whole of January and no action had been taken. This puts people at risk of receiving medication which has been stored at temperatures greater than the manufacturers recommendation and may make medicine unsafe to administer. The date of opening of medicines with a limited use once open is not always recorded. This means that there is a risk that medication is used beyond the date recommended by the manufacturer. The care plans need to be updated to provide detailed information on the persons medication and medical condition especially for people with anticoagulation medication. The home should have a current record of INR result and current dosage available at all times. Such details are important as it means that staff have up to date information on the care requirements for that person. Controlled drugs storage appears to meet regulations. However some entries which were made in the controlled drugs register were not signed for on the MAR charts and one entry for Oramorph liquid was made on the MAR chart but had not been entered in the register. What the care home does well:
There is a comprehensive set of policies and guidance so staff understand how to handle and administer medication safely.
Care Homes for Older People Page 4 of 10 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 Ensure that service user plans clearly identify how their needs in respect of health and welfare are to be met. To make sure that people receive the appropriate care to meet all of their needs. 26/02/2010 2 7 15 Ensure that care plans are 26/02/2010 kept under review and where appropriate and, unless it is impracticable after consultation with the service user or a representative of his, revised to reflect the service users changing health and welfare needs. To make sure that people receive the appropriate care to meet all of their needs. 3 29 19 Evidence must be obtained that individual agency staff employed by the home have had satisfactory recruitment checks. To promote the safety and wellbeing of service users. 20/02/2009 4 37 17 Maintain adequate records of 26/02/2010 any service user accident and a record of falls and treatment provided to
Page 6 of 10 Care Homes for Older People 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 service users as detailed in paragraphs (j) and (o) of Schedule 3 of the Care Homes Regulations 2001. To demonstrate that people receive the appropriate care following a fall. 5 38 12 Ensure that all staff adhere to safe and appropriate accident management and emergency first aid procedures. So that people receive the appropriate care following an accident. 26/02/2010 Care Homes for Older People Page 7 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 1 9 13 A system must be in place to 16/03/2010 check expiry dates of medicines and medication with a limited use once opened. This makes sure medication is safe to administer 2 9 12 Arrangements must be in place to ensure that there is an effective system in place to obtain and retain adequate supplies of prescribed medication. This makes sure that people can be given medication as prescribed and treatment of their medical condition is not affected 16/03/2010 3 9 13 Medication must be given as 16/03/2010 prescribed and a record must be made at the time that it is given This will make sure that people receive their medications correctly and the treatment of their medical Care Homes for Older People Page 8 of 10 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 condition is not affected 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 The temperature of the medication rooms should be regularly recorded and action taken if temperature fall outside those recommended by the manufacturer. A system should be in place to record all medication received into the home and medication carried over from a previous month. This helps confirm that medication is being given as prescribed and when checking stock levels. Handwritten entries and changes to MAR charts must be made accurately recorded and detailed. This makes sure that the correct information is recorded and a person receives their medication as prescribed 2 9 3 9 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!
