Care Home: Dalkeith

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What the care home does well Medication needed by people living in the home were in stock. Medicine records indicated that people living in the home had received their medicines correctly. Staff support some people to self medicate. What the care home could do better: Make sure that risk assessments for people who self medicate are up to date and that records are kept when any medicines are given to people to look after in their rooms. Use a lockable carrying case or other secure means of taking medicines around the home when the trolley is not used so that medicines can be easily secured in the event of an emergency arising that staff have to deal with.Make sure the times of medicine administration on the record charts are a more accurate reflection of the times when medicines are administered. Risk assess and review the safety of the arrangements for night staff administering medicines in the morning. Make sure that the actual dose of medicine administered is always recorded where a variable dose is prescribed and that directions for eye drops indicate which eye(s) is to be treated. Make sure accurate and complete records are kept about the use of any prescribed food supplements. Make sure the allergy section of the medicine chart is always completed. Make arrangements to keep medicine administration charts up to date by clarifying which medicines are not in current use and to liaise regularly with the pharmacy to remove such medicines from the printed charts. Make sure that there is clear written guidance to staff on how to reach decisions for any medicine prescribed to be administered `when required` and how staff are to reach the decision to administer. This is especially when people in the home are not able to ask when they need these and also to take account of the provisions of the Mental Capacity Act 2005. Review and improve monthly stock control arrangements so as to minimise any wastage as outlined in the report above. Make sure that medicines needing to be kept in the medicine fridge are in fact stored there and that this fridge is regularly defrosted and is always running within the temperature range of 2 to 8 degrees centigrade. Record the medicine room temperature daily and take appropriate action should the temperature routinely exceed 25 degrees centigrade. Always read the manufacturers` instructions about in use expiry dates for medicines (for example the eye drops, capsules and liquid medicine found at this inspection) and make sure that these are followed. Upgrade the storage arrangements for controlled drugs to comply with the Misuse of Drugs (Safe Custody Regulations) 1973. Make sure that records kept in the controlled medicine record book are always complete and accurate. Investigate the stock balance anomalies we pointed out at this inspection and take appropriate action to deal with these. Consider using an oral medicine syringe to more accurately measure a 2.5ml medicine dose. Some parts of medication policy and procedures need reviewing and made readilyavailable for staff to refer to. Any old policy, procedures and guidance must be removed to avoid confusion. Please note, outstanding statutory requirement 1 listed below was not followed up at this specialist medication inspection so is still listed. This will be checked as properly actioned at a future inspection. Random inspection report Care homes for older people Name: Address: Dalkeith 285 Gloucester Road Cheltenham Glos GL51 7AD 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: David Jones Date: 2 4 0 8 2 0 0 9 Information about the care home Name of care home: Address: Dalkeith 285 Gloucester Road Cheltenham Glos GL51 7AD 01242522209 01242522209 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Camelot Healthcare Ltd care home 22 Number of places (if applicable): Under 65 Over 65 22 old age, not falling within any other category Conditions of registration: 0 The maximum number of service users who can be accomodated is 22. The registered person may provide the following category of service only: Care home providing personal care - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Since October 2007 Camelot Healthcare Limited are the new providers. Dalkeith is an adapted older property, which has retained a number of its period features. It is located in the St Marks area of Cheltenham. There is a post office/newsagent about 500 metres along the road, which is one of the main roads into the town. Buses pass the front door and the railway station is close by. The accommodation is on four floors with a shaft lift providing access between the Care Homes for Older People Page 2 of 15 Brief description of the care home ground floor and the first floor and a stair lift from the basement bedroom to the ground floor. The communal rooms consist of four lounge areas, two of which also have a dining area and one lounge area is on the first floor. Sixteen bedrooms have en-suite facilities. Two of these have a bath and shower respectively. Four bedrooms have wash hand basins only. There are three bathrooms two of which are assisted. Of these, one has a bath hoist and the other is a `walk in? bath. There are large gardens, and seating areas at the rear of the home. Parking for several cars is available at the front of the home. The accommodation fees range from approximately 485.00 to 625.00 pounds based on facilities/room size and additional charges include hairdressing, chiropody, escort duties and newspapers. Information regarding how fees are calculated and the criteria for when local authority funded places are available is in the homes Service User Guide. Care Homes for Older People Page 3 of 15 What we found: Pharmacist inspectors report about arrangements for the handling of medicines that were inspected at a random inspection on 24th August 2009. At this random inspection one of our (the Care Quality Commission) pharmacist inspectors specifically examined some of the arrangements for the handling of medicines. The home had kept us informed about a problem with medication earlier in the year and the action taken to deal with this. Our inspection was to check that there were still safe arrangements in place for administering and handling medicines in this home. We looked at some stocks and storage arrangements for medicines and various records about medication. We spoke to the deputy manager and another member of staff who administered medication. In the afternoon we spoke to several people who were sitting in the lounge. We gave feedback at the end of the inspection to the deputy manager. The inspection took place during a five hour period on a Monday. We thank the staff for their assistance during our visit. At the time of this inspection staff supported one person living in the home to self medicate and look after some of his/her medicines. Staff also supported another person to apply a cream. We looked at the risk assessment for these arrangements for one person and found this needed to be kept up to date as one medicine staff administered was not included. It also included eye drops that were no longer used. Monthly reviews were not in place as the last was signed on 28 May 2009. Staff also need to record the quantities of each medicine handed to the person to look after with the date. This helps with checks that the right quantity of medication is being used. One staff member told us they check this each day. The rest of the people living in this home were therefore totally dependent on the staff for this part of their care. Care staff who had undertaken medication training were responsible for handling and administering all medicines to people living in the home. We spoke to two members of staff about this training but were not able to look at training records as the manager designate was on leave. These staff members also demonstrated knowledge of medicines used and peoples needs but we did find evidence (see below) that knowledge about the correct handling of eye drops may be lacking. There was a list of staff authorised to administer medicines including their signatures and initials so that we could tell from the records who had signed for particular doses. At lunchtime staff administered medicines to people living in the home. They took the full packs of medicines with the records downstairs to where people were sitting. A locked medicine trolley was available but was not always taken downstairs when only a few medicines were needed. We discussed the times for giving medication, particularly about making sure that there is at least a four hour interval between doses of certain medicines and also to achieve an even spread of doses throughout the day. This helps get the best effect from medicines such as painkillers and antibiotics. The staff we spoke to were aware of this. We noted Care Homes for Older People Page 4 of 15 that the pharmacy printed times for medicine administration on the medicine record charts but these were not in fact the times when medicines were always administered so staff were signing against the wrong time in some cases. For example staff told us that the morning medicines were administered by night staff about 6.30am yet the medicine records all stated 8am. Staff told us that most people would be awake at this time and they would not wake people for their medicines. The advantage of giving medicines around this time is that there is a better spread of doses throughout the day and there is a more appropriate interval before the lunch doses. We had some concern however that staff who had been on duty all night were responsible for administering all the morning medicines. There are the greatest number of medicines to administer in the morning and it is not regarded as good practice for staff who have been on duty all night to be responsible for this. They may lack concentration as they are tired and wanting to get off duty. Staff also told us that some other printed administration times were different in practice. We looked at records for one person who has some medication administered in a particular way and saw that these had been developed to make sure that their best interest was considered. We also spoke to the deputy manager about any cultural or equality and diversity issues affecting medication for people living in this home particularly as this inspection took place during Ramadan when people of Muslim faith may wish to fast. This can affect treatment with some medicines. The deputy manager told us that there was nothing related to medication they have identified for anyone in the home at the moment and nobody was fasting. There were arrangements for keeping records about medication received, administered and leaving the home or disposed of (as no longer needed) for each person living in the home. Accurate, clear and complete records about medication are very important in a care home so that people are not at risk from mistakes with their medicines and so that there is a full account of the medicines the home is responsible for on behalf of the people living there. We looked at some medication records for the previous last two weeks and these showed routinely administered medicines were all signed as administered and that these medicines were all in stock. This indicated that people living in the home were receiving their medicines as prescribed. We also made some checks of the packs of medicines on the trolley which also helped to confirm this. We noted just a few issues from the records. For one person who was prescribed a variable dose of one or two tablets staff did not always record what dose they gave. Staff we spoke to gave a different response about the dose taken. We noted that the allergy box on the medicine charts recorded a penicillin allergy for one person. This box was blank on the other charts. It is good practice to ask the pharmacy to print an entry in here even if this is none known so that it clear this has been considered. Staff told us they were not aware of any other allergies. We also saw that some people were prescribed eye drops but the records did not always indicate which eye. Staff were able to tell us about this. One person was recently prescribed a cream but the records were not signed to indicate it was applied. This cream should have been kept in the fridge but we found one new tube on the trolley and another in the medicine cupboard. We noted that some medicine charts seemed to contain medicines that were no longer in use but this was not clearly indicated. Some people living in the home were prescribed medication only to use when required. Staff gave us some explanation about how they would use some of these medicines and Care Homes for Older People Page 5 of 15 that in some cases the person would be able to state their need for a particular medicine. It is important that there is clear written guidance for each person about how such a medicine is to be used to meet their identified needs. We discussed with the deputy manager straightforward ways to achieve this. Any consideration of the requirements of the Mental Capacity Act 2005 must be included. We saw in one case the use of medication for pain was included in a care plan. We looked in some other care plans and found that some needed updating as information about medication was not current. The monthly reviews were not always signed as carried out. Two people were prescribed liquid food supplements. We saw some records in place but there were none for a third person who we found supplies for in the medicine room. The care plans for these people needed reviewing as there was wrong information about the product used. This is an important part of treatment that the doctor has prescribed so care plans need to include full up to date information about intended use and be reviewed regularly. We have published information about administration and recording of creams and nutritional supplements on our website (www.cqc.org.uk) so this must be followed. We looked at the arrangements provided for storing the medicines and although these were generally suitable there were some matters needing attention. The room felt warm and a temperature of 25.6 degrees centigrade was recorded. This is very slightly above the maximum recommended for medicine storage. It was possible the heat gain from the medicine fridge kept in this closed room could be the reason for this. The medicine fridge was too cold at the time we inspected; this could lead to degradation of medicines stored in here. There were arrangements for recording the temperature in the medicine fridge and these also showed that it had previously sometimes been too cold. This gave the wrong temperature range for a medicine fridge (0 to 5 degrees centigrade but it should be 2 to 8 degrees centigrade). The temperature control on the fridge was adjusted during the inspection. The fridge needed defrosting as there was a considerable build up of ice. The temperature probe for the thermometer may be in the wrong place as it was positioned close to the ice box. There was a metal medicine cabinet but there was no separate storage for controlled medicines so these arrangements do not comply with the Misuse of Drugs (Safe Custody) Regulations 1973. All care home must comply with this now to make sure of safe storage for this group of medicines. We publish information about this on our website (ww.cqc.org.uk) so this must be followed. There was a standard record book in place for keeping the extra records needed for this group of medicines. More attention to detail in these records were needed in order to keep a full account of these medicines. Some pages did not have a proper heading with the strength or even name of the medicine. Some entries were crossed out which is very poor practice and there were some medicines included in here which should not be included in these records. The stock balances on some pages were wrong as stock was showing that was not in the home. The deputy manager said these medicines had been returned when people had left the home. The stock balance for one liquid was higher than the calculated balance from the number of doses given. This was probably due to slight variation in measuring a 2.5ml dose over a period. The deputy manager showed us the spoon used to measure. It may be better to ask the pharmacy to supply a proper oral syringe to measure this dose which would be easier and more accurate. We suggested for liquid medication like this to balance the stock and note any differences when each bottle is used up rather than keeping records for a number of different bottles on the same page. We found some stock totals had been changed down by one for some 30mg tablets on two separate pages (40 and 43). This Care Homes for Older People Page 6 of 15 looked as though two tablets could not be accounted for and the deputy manager could not explain this but thought in one case a tablet had been dropped. This must always be noted so as to explain discrepancies like this. We found arrangements for eye drops were not well managed. Staff were not sure about period of use once opened (which is four weeks in order to reduce risks of contamination). On the trolley there was an eye drop bottle with an opening date on 20.07.09 (more than four weeks in use) and another bottle with no opening date. The deputy manager immediately replaced these with new stock that was in cupboard. Other packs of medicines on the trolley were generally not dated when opened. There were at least two containers of capsules which have a six week period of use after opening and also a liquid medicine where the manufacturer specifies a 90 day period of use after opening but there were no opening dates on these containers. The supplying pharmacy should be able to provide information about discard dates after first opening. The home returned unused medicines to the pharmacy at the end of each month. Care is needed not to waste NHS resources as with proper stock control some medicines may not need ordering every month. Unused stock could be used the next month with records of amounts carried forward on the medicine charts as an audit method. Staff should then only order new stock of what is actually wanted. We also explained the way audit checks can be made of medicines if dates of opening were written on packs. In the medication room there was medication policy written in 2002 by the previous owners of the home so this should not be in use. The guidelines from the Royal Pharmaceutical Society about handling medicines in care homes was the 2003 edition which is out of date as a new different edition was published in 2007. Before this inspection the company operations manager had sent us detailed medication procedures for this home and the deputy manager found these in the office. Some of the information in here was not what we found in the home and some other issues about handling medicines need including or clarifying so that staff have clear direction about how the company expect them to manage and handle medication. This new policy needs to be readily available for staff. There was an up to date medicine reference book for staff to refer to. What the care home does well: What they could do better: Make sure that risk assessments for people who self medicate are up to date and that records are kept when any medicines are given to people to look after in their rooms. Use a lockable carrying case or other secure means of taking medicines around the home when the trolley is not used so that medicines can be easily secured in the event of an emergency arising that staff have to deal with. Care Homes for Older People Page 7 of 15 Make sure the times of medicine administration on the record charts are a more accurate reflection of the times when medicines are administered. Risk assess and review the safety of the arrangements for night staff administering medicines in the morning. Make sure that the actual dose of medicine administered is always recorded where a variable dose is prescribed and that directions for eye drops indicate which eye(s) is to be treated. Make sure accurate and complete records are kept about the use of any prescribed food supplements. Make sure the allergy section of the medicine chart is always completed. Make arrangements to keep medicine administration charts up to date by clarifying which medicines are not in current use and to liaise regularly with the pharmacy to remove such medicines from the printed charts. Make sure that there is clear written guidance to staff on how to reach decisions for any medicine prescribed to be administered when required and how staff are to reach the decision to administer. This is especially when people in the home are not able to ask when they need these and also to take account of the provisions of the Mental Capacity Act 2005. Review and improve monthly stock control arrangements so as to minimise any wastage as outlined in the report above. Make sure that medicines needing to be kept in the medicine fridge are in fact stored there and that this fridge is regularly defrosted and is always running within the temperature range of 2 to 8 degrees centigrade. Record the medicine room temperature daily and take appropriate action should the temperature routinely exceed 25 degrees centigrade. Always read the manufacturers instructions about in use expiry dates for medicines (for example the eye drops, capsules and liquid medicine found at this inspection) and make sure that these are followed. Upgrade the storage arrangements for controlled drugs to comply with the Misuse of Drugs (Safe Custody Regulations) 1973. Make sure that records kept in the controlled medicine record book are always complete and accurate. Investigate the stock balance anomalies we pointed out at this inspection and take appropriate action to deal with these. Consider using an oral medicine syringe to more accurately measure a 2.5ml medicine dose. Some parts of medication policy and procedures need reviewing and made readily Care Homes for Older People Page 8 of 15 available for staff to refer to. Any old policy, procedures and guidance must be removed to avoid confusion. Please note, outstanding statutory requirement 1 listed below was not followed up at this specialist medication inspection so is still listed. This will be checked as properly actioned at a future inspection. 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 9 of 15 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 27 18 The registered person must 04/07/2008 ensure that there are sufficient care staff on duty at peak periods of activity to help meet peoples needs. Not inspected at random inspection on 24th August 2009 but will be checked as properly actioned at a future inspection. Care Homes for Older People Page 10 of 15 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 Make arrangements to risk 01/11/2009 assess and modify the arrangements for administering medicines particularly to address the risks of night staff administering all the morning medicines and to have a secure method of carrying medicines around the home when the medicine trolley is not used. This will make sure that people are not put at unnecessary risk from medicines because of unsafe practices. 2 9 13 Always keep accurate and 01/10/2009 complete records in the controlled drug record book. Investigate the stock balance anomalies identified at this inspection and take appropriate action to deal with these. This is to help make sure that all these medicines are properly accounted for and Care Homes for Older People Page 11 of 15 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 people have received the correct doses. 3 9 13 Update storage arrangements so that the provisions of the Misuse of Drugs (Safe Custody) Regulations 1973 are complied with when any controlled drugs are kept in the home. This is to make sure of safe storage of these medicines and to comply with the law 4 9 13 Make sure that the medicine 01/10/2009 fridge is always kept in the correct temperature range of 2 to 8 degrees centigrade and action is always taken to correct this if it is found to be at the wrong temperature. This is to make sure that medicines are stored at the right temperature as directed by the manufacturers in order to maintain their correct potency and not put people living in the home at risk from using medicines that are no longer stable. 5 9 13 Always keep accurate, clear 01/10/2009 and complete records about any medication kept in the home and administered to people who live in the home. (This is to particularly address the issues identified in the report). This is to help make sure all Care Homes for Older People Page 12 of 15 01/12/2009 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 medicines are accounted for and that people are not at risk of mistakes with medication because of incomplete or inaccurate records. 6 9 13 Review medicine records and 01/11/2009 care plans for people living in the home to make sure that for all medicines prescribed with a direction when required or with a variable dose there is clear, up to date and detailed written guidance on how to reach decisions to administer the medicine and at a particular dose, taking into account the provisions of the Mental Capacity Act 2005. This will help to make sure people living in the home receive the correct amounts of medication in a consistent way in line with planned actions. 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 2 9 9 Use a proper oral medicine syringe to measure a 2.5ml medicine dose. Record the medicine room temperature daily and take appropriate action should the temperature routinely exceed 25 degrees centigrade. Review and update the medicine policy and local procedures and make sure these are readily available so as Page 13 of 15 3 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 to provide all staff with clear direction about the way medicines are safely managed and handled in this home. 4 9 Make arrangements to write the date on containers of any medicines when they are first opened to use and record the quantity of any stocks of medicines that are carried forward to the next medication cycle. This is to help with good stock rotation in accordance with the manufacturers or good practice directions and to enable audit checks that medicines are being used correctly and the right quantities remain in stock. Care Homes for Older People Page 14 of 15 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 15 of 15 - 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. 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