This inspection was carried out on 8th February 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.
Random inspection report
Care homes for older people
Name: Address: Wellburn House Wellburn Road Fairfield Stockton-on-Tees TS19 7PP two star good 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: Janet Long Date: 0 8 0 2 2 0 1 0 Information about the care home
Name of care home: Address: Wellburn House Wellburn Road Fairfield Stockton-on-Tees TS19 7PP 01642647400 01642647411 wellburn@schealthcare.co.uk www.southerncrosshealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Janice Mulloy Type of registration: Number of places registered: Conditions of registration: Category(ies) : Southern Cross BC OpCo Ltd care home 90 Number of places (if applicable): Under 65 Over 65 0 90 dementia old age, not falling within any other category Conditions of registration: 90 0 The maximum number of service users who can be accommodated is: 90 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: Old Age, not falling within any other category, Code OP - maximum number of places 90 Dementia Code DE, maximum number of places 90 Date of last inspection Care Homes for Older People Page 2 of 9 Brief description of the care home Wellburn House is a modern, purpose built facility that is registered to provide personal care to ninety older people. The home does not provide intermediate care. The first floor of the home has accommodation for forty-five older people with dementia and the ground floor has accommodation for forty-five older people receiving general personal care. All bedrooms on the first floor of the home are single in nature. There are forty-three single bedrooms and one large bedroom that can be used as a shared bedroom on the ground floor of the home. Bedrooms have en-suites facilities with a toilet and washbasin. The home is divided into three units; each has a Unit Manager and a dedicated staff team. The Unit Managers are responsible to the Registered Manager. All rooms are comfortably furnished and residents may personalise their rooms. Bedrooms in the home environment meet space requirements of National Minimum Standards. There is an enclosed rear garden that has seating areas. Care Homes for Older People Page 3 of 9 What we found:
This pharmacist inspection lasted six hours and was carried out as a follow up to a number of medication issues in this home. During this visit we examined medication policy and procedure, the current medication administration record (MAR), and the medication ordering, storage and handling arrangements. Some care planning was looked at with regard to medication. Standard policy documentation was available in the home. There was a good Homely Remedies policy and laminated consent documents were stored alongside the MARs. Individual medication care plans should be more detailed and updated to provide 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. Such details are important as it means that staff have up to date information on the care requirements for that person and written confirmation of current dosage. Medication Audit was included in the policy documents and written audits had been completed in September and October, since then written documentation was not available. On one unit there is no record of staff authorised to administer medicines. This makes it difficult to identify who was involved in administration if a problem or error was to occur. A number of MAR entries had gaps and did not have complete records of administration. Some medication was given at a dosage different to that prescribed and written up on the MAR. To demonstrate that people are getting their medication as prescribed the MAR chart should record each administration. An audit of current stock and MAR records showed that some medication had been signed for but not given. For one person medication had been signed for on the MAR chart but was still in the blister pack supplied by the pharmacy. The MAR records for creams and nutritional supplements were incomplete. In some cases creams prescribed for application twice daily were only signed for on the MAR once daily. There is inconsistency in handwritten entries, the quantity of medication supplied and the date received. To make sure there is an accurate record the quantity supplied, the date of entry, the signature of the person making the entry and a witness signature where possible should be included. Some people self-administer creams, inhalers and eye drops. For many of these people there was no record of a risk assessment. It is important that a thorough risk assessment is done to make sure that the person is able to safely administer their medication as intended. There is a standard lockable medicines trolley on each unit and spare stock is mainly kept in lockable cupboards. Records were kept for fridge and room temperature. However on one unit the recorded temperatures showed storage conditions greater than those
Care Homes for Older People Page 4 of 9 recommended by the manufacturer on a number of occasions. The date of opening of medicines with a limited use once opened is not always recorded. This means there is a risk that the medication may be used beyond the date recommended by the manufacturer and may not be safe to administer. 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 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 30 13(6)18(C)(i) All staff must be given training in the Mental Capacity Act 2005 to ensure that they have the knowledge and understanding of their responsibilities under this legislation. 01/02/2009 Care Homes for Older People Page 6 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 1 9 13 Medication must be given as 24/04/2010 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 condition is not affected. 2 9 13 System must be in place to check expiry dates of medicines and medication with a limited use once opened. This makes sure medication is safe to administer by reducing the risk of contamination. 24/04/2010 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 room should be regularly monitored. This makes sure that medicines are
Page 7 of 9 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 stored at a temperature recommended by the manufacturer 2 9 Handwritten entries should be accurately recorded and detailed. This makes sure that the correct information is recorded 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. © 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 9 of 9 - 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!
