Care Home: Dalby Court Care Home

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What the care home does well Medication was stored securely and safely. What the care home could do better: Records need to be kept of medication received and carried forward especially for handwritten entries so that audit of medication is possible. The MAR records for creams and nutritional supplements need to be improved so that a complete and accurate record is kept. Medication policy should be updated. Random inspection report Care homes for older people Name: Address: Dalby Court Care Home 1 Dalby Court Coulby Newham Middlesbrough Cleveland TS8 0XE two star good service 19/10/2009 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: 0 8 0 3 2 0 1 0 Information about the care home Name of care home: Address: Dalby Court Care Home 1 Dalby Court Coulby Newham Middlesbrough Cleveland TS8 0XE 01642578000 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) European Care (GB) Ltd Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 68 Number of places (if applicable): Under 65 Over 65 0 old age, not falling within any other category Conditions of registration: Maximum number of places 68 68 The registered person may provide the follow category of care service only : Care home - Code PC. To service users of the following gender : Either whose primary care needs on admission are within the following categories : Old age not falling within any other category : Code OP Date of last inspection Brief description of the care home Dalby Court is a large residential care home that can provide accommodation for up to 68 older people. Accommodation is provided over two floors and includes a range of different communal lounge and dining areas. All bedrooms have en-suite toilet and Care Homes for Older People Page 2 of 9 1 9 1 0 2 0 0 9 Brief description of the care home wash hand basin facilities and built in wardrobes. There are garden areas around the building and an enclosed garden area that provides a safe environment for people to enjoy. Car parking is available directly in front of the building. Local transport and shops are nearby. As of 19 October 2009, the fees for this home are £458 - £488 per week. The fees include 24 hour care, food and laundry services. Please contact the manager for more details on fees and what they include. Care Homes for Older People Page 3 of 9 What we found: The pharmacist inspection lasted six hours and was carried out to looks at medication concerns due to a number of reported issues. During the visit we looked medication policy and procedures, the current medication administration record (MAR), and medication ordering storage and handling arrangements. We also looked at a number of care plan sections with regard to medication. The medication policy needs to be reviewed. The current policy has not been updated since the home had a change of ownership. It is important to have an up to date policy so that staff have guidance on good practise and current legislation to make sure that safe practises are followed. Photographs were missing from several MAR chart dividers. It is important to have photographs to reduce the risk of medication being given to the wrong person. There were few gaps on MAR charts indicating that medication is mainly given as prescribed however the MAR records for nutritional supplements and creams were incomplete. 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 always recorded on the new MAR and often no quantity is recorded on handwritten entries. This means it is difficult to have a complete record of medication within the home and to check if medication is being administered correctly. One MAR contained several alterations and changes to medication. To make sure that there is an clear and accurate record the date of change and the person authorising the change should be noted. The code C was used on a number of occasions to record carers notes overleaf. However often there was no note made to explain why medication had not been given. It is important that a clear note is made so there is accurate information on how a person is taking their medication. Medicines are stored securely either in locked trolleys or locked cupboards. There were good records of fridge and room temperature however one fridge was showing a temperature of less than two degrees centigrade which is cooler than the temperature recommended by manufacturers and may make medicine unsafe to administer. Some people had several tubs of creams stored in their room with no date of opening marked on the pot. For one person eye drops which were marked with a date of opening were in use after the 28 days recommended. Eleven people self-administer medication from their MAR charts but there was no record of a risk assessment for six of these people. It is important that a thorough risk assessment is done to make sure the person is able to safely administer their medication Care Homes for Older People Page 4 of 9 as intended. 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 that staff have up to date information on the care requirements for that person. Where the care requirements change a note should be made to reflect this in the care plan in a timely manner. 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 £ No R 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 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 A system should be in place 07/06/2010 to check expiry dates for medication with a limited use once open. This makes sure medication is safe to administer by reducing the risk of contamination. 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 medication policy should be updated in line with current guidance so that staff understand how to handle and administer medicines safely. A current photograph of each person should be attached to their MAR chart. This helps reduce the risk of medication being given to the wrong person. Handwritten entries and changes to MAR charts should be accurately recorded and detailed. Codes used to record why medication administration has not taken place must be clearly defined so detailed information on a persons medical treatment can be obtained. Page 7 of 9 2 9 3 4 9 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 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. 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