Latest Inspection
This is the latest available inspection report for this service, carried out on 8th March 2010. CQC found this care home to be providing an Excellent 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.
For extracts, read the latest CQC inspection for Leabrook House Nursing Home.
What the care home does well Overall, medication control and handling had improved since the key inspection. Records were generally kept up to date and storage of peoples medication was secure. What the care home could do better: The service needs to ensure that all prescribed creams and ointments are recorded when they are applied in order to ensure that the healthcare needs of people are being met. The service needs to ensure that medicines are available to administer to people and that all communication with the healthcare professionals is also recorded. The service needs to ensure that controlled drugs are stored securely according to legal requirements. Random inspection report
Care homes for adults (18-65 years)
Name: Address: Leabrook House Nursing Home 180/181 Leabrook Road Tipton West Midlands DY4 0DY three star excellent 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: Morag Ross Date: 0 8 0 3 2 0 1 0 Information about the care home
Name of care home: Address: Leabrook House Nursing Home 180/181 Leabrook Road Tipton West Midlands DY4 0DY 01215565685 01215565685 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Julia Handley Type of registration: Number of places registered: Conditions of registration: Category(ies) : Leabrook House Limited care home 41 Number of places (if applicable): Under 65 Over 65 0 0 learning disability physical disability Conditions of registration: 3 41 The maximum number of service users who can be accommodated is: 41 The registered person may provide the following 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: Learning disability (LD) 3 Physical Disability (PD) 41 Date of last inspection Brief description of the care home Leabrook House is situated on the Tipton/Wednesbury border, close to the towns of West Bromwich, Walsall, and Wolverhampton. It is within easy reach of several motorway/main road networks, with good availability of public transport.
Care Homes for Adults (18-65 years) Page 2 of 10 Brief description of the care home The Home offers 31 single occupancy rooms, of which fifteen have en-suite with showers and another six have toilet and hand wash basin facilities. There are a range of services and facilities available to people living at the home including:entertainment and recreational activities, various aids and adaptations, complimentary and relaxation therapies, a swimming/hydrotherapy pool and an excellent catering service. The Home also provides a 10 place day-care facility for younger adults with specific nursing needs. The current scale of charges are £440 to £1400 each week. Care Homes for Adults (18-65 years) Page 3 of 10 What we found:
The pharmacist inspector visited the home on 8th March 2010 to check the management and control of medicines within the service. A previous key inspection on 12th January 2010 had identified some medication issues, which resulted in an immediate requirement being made. We received a written response from Monica Lovell, Director on 18th February 2010, which informed us that the medication requirements had been met. The reason for this inspection was to check compliance with the requirements relating to medication. We spoke to two members of the nursing staff team. We saw that medication was secure. For example, there was a locked room used to store peoples medication and a locked medicine trolley. We found that the storage temperatures of medicines were being monitored each day including the room and the refrigerator temperature. The temperatures were all within the recommended safe storage temperatures for medication. We saw that medication was stored neatly and tidily which made it very easy to locate peoples medication. There was no overstocking of medication and only medication that was required was kept. This means that medication was stored securely and was well organised, which helped to ensure that people who use the service were protected from harm. A medication policy was available dated 13th February 2005 and we were informed that this was in the process of being updated using the Royal Pharmaceutical Society of Great Britain guidance and also the Nursing and Midwifery Council (NMC) guidance. We found guidelines for the administration of medication via enteral feeding tubes were available for staff to check that people with a special feeding tube (PEG tube) would have their medicine given to them safely.We were informed that the new guidelines provided by NEWT were also going to be obtained to keep their information up to date. Staff informed us that they discuss any special medicine requirements, such as PEG feeds, with the persons GP. For example, we saw a letter from one persons GP which informed the home that it was in the persons best interest to receive their medication through a PEG feeding tube. We were informed that staff have updates on PEG feeding. This means that nursing staff are able to understand and deal with peoples medicine requirements to suit their individual needs. Some people were prescribed medicines to be given on a when required or as needed basis. We saw written protocols available for each person who was prescribed medication in this way. For example, one person had been prescribed a medicine to help calm and control their behaviour. We saw a record which stated that the medicine was only to be given for distressed or agitated behaviour. We looked at the Medication Administration Record (MAR) chart for the person and saw that none had been given. The nurses explained that the person did not require them as they had settled very well into the home and this medicine was going to be reviewed with the GP. This means that there were written protocols available for staff to follow and ensure that the health and welfare of people living in the home were protected. The controlled drug cabinet, which is used to store certain medicines, was not secured according to the requirements of the Misuse of Drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations 1973. This means that there was inadequate arrangements in the home to meet legal requirements and ensure secure storage of peoples medication.
Care Homes for Adults (18-65 years) Page 4 of 10 We looked at all of the MAR charts, which were printed by the pharmacy. The majority were documented with a signature to show that medication had been given to the person or a code was documented to show the reason why a medicine was not given. However, we found that prescribed creams and ointments were not recorded when they were applied. For example, one person was prescribed a cream to be applied twice a day for an inflammatory skin disorder such as eczema. We saw gaps on the MAR chart and also the use of ticks rather than the initials of the person who applied it. We discussed this with two nurses who informed us that it was usually the care staff team who applied any creams or ointments and agreed that this would need to be recorded as well. This means that overall medication was recorded when it was given but the records for prescribed creams or ointments were not documented to show if they had been applied. Sometimes medication was not available to administer to people. For example, we found that two people had not been given their medicine because it was not available. We saw that the MAR charts had been documented with a code o or other reason for not giving the medicine. One person had been prescribed a vitamin preparation and the other person had been prescribed an iron preparation. The reason stated on the MAR charts for both people was no stock. We were informed by the nurses that both people had been discharged from hospital on the medicines but no further prescription had been supplied by the GP. It was therefore not clear whether the medicine was to be continued or whether it should be stopped. It was agreed that the service needed to contact the GP. This means that two people were without prescribed medication from the hospital but there was no further information available to ensure the continued healthcare needs of the people. We saw current records for the receipt and disposal of medication. The date of opening of boxes and bottles of medicines were usually recorded and balances of medication were carried forward from old records to new records. These records helped to ensure there was a clear audit trail of medication. We found that counts and checks made on the majority of medicines were accurate, which showed that the service was giving medicines to people as prescribed. 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 Adults (18-65 years) Page 5 of 10 Care Homes for Adults (18-65 years) Page 6 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 14 The home should obtain a copy of the funding assessment prior to people moving into the home. This will ensure they have all the information to make an informed decision as to whether they can meet that person needs. 26/02/2010 Care Homes for Adults (18-65 years) 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 The service must make 08/04/2010 arrangements to ensure that controlled drugs are stored securely in accordance with the requirements of the Misuse of Drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations 1973 and in accordance with the guidelines from the Royal Pharmaceutical Society of Great Britain. This is to ensure the service meets the necessary legal requirements for the safe storage of peoples medication. 2 9 12 The service should ensure that there is an effective system in place to request, obtain and retain adequate supplies of prescribed medicines for service users so that they can be given them as and when prescribed. This is to ensure that there is continued healthcare for 08/04/2010 Care Homes for Adults (18-65 years) 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 people who live in the home. 3 9 13 The service needs to make 08/04/2010 arrangements to ensure that medication administration records are accurately maintained, including recording the application of prescribed creams and ointments and that the reasons for nonadministration of medication are recorded by the timely entry of an appropriate code or entry on the medication administration record. This is to ensure that the service maintains accurate medication records. 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 1 The home should produce Service User Guides and Statement of Purposes in suitable alternative formats for people living at the home so that they have information that allows them to make infomred decisions. ( Recommendation made at key inspection visit December 2010 not checked at this visit) Care Homes for Adults (18-65 years) 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 Adults (18-65 years) 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 Adults (18-65 years) 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!
