Care Home: Madeleine House

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What the care home does well Accidents and incidences are reported to us and where required other health careprofessionals are involved. The home has developed a good auditing system to ensure the administering of medication is regularly audited and where errors are identified reported immediately. What the care home could do better: The responsible person who visits the home each month and reports on how the home is being run, should ensure a full report is undertaken. This will ensure the home is run in peoples best interest and also support the manager with any concerns or issues that have been identified. The home should consider introducing a system that will allow staff to monitor more closely when people have had a fall for any developing injuries. Random inspection report Care homes for older people Name: Address: Madeleine House 60 Manor Road Stechford Birmingham West Midlands B33 8EJ one star adequate service 22/02/2010 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: Sue Scully Date: 1 1 0 5 2 0 1 0 Information about the care home Name of care home: Address: Madeleine House 60 Manor Road Stechford Birmingham West Midlands B33 8EJ 01217861479 01217850621 Telephone number: Fax number: Email address: Provider web address: www.anchor.org.uk Name of registered provider(s): Name of registered manager (if applicable) Mrs Linda Jayne Bryant Type of registration: Number of places registered: Conditions of registration: Category(ies) : Anchor Trust care home 41 Number of places (if applicable): Under 65 Over 65 0 41 41 dementia old age, not falling within any other category physical disability Conditions of registration: 10 0 0 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 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 (OP) 41 Physical disability - over 65 years of age (PD(E)) 41 Dementia (DE) 10 Date of last inspection Care Homes for Older People 0 9 1 1 2 0 0 9 Page 2 of 9 Brief description of the care home Madeleine House is registered to provide residential care for up to 41 residents who are over 65 years of age and require assistance for reason of old age and physical disability. This includes ten residents who can be accommodated for reasons of dementia care. The Home is owned and managed by Anchor Trust. It is a modern two storey building set back off the road in its own grounds with adequate off road parking to the front of the building. It is well maintained internally and externally and is run as one unit. Care Homes for Older People Page 3 of 9 What we found: A Random inspection was undertaken to the service following a number of notifications that we had been told about by the home that gave us cause for concern. Notifications are when the home tells us about things that have happened in the home that effect the welfare of the people living there, such as accidents and incidents. We had been notified about a high number of accidents and incidents that had happened in the home in the month of April which also included concerns in relation to medication. Two inspectors visited the home, one being a pharmacy inspector to establish if the people living in the home were at risk of harm. We looked at records that would cross reference to the notifications we had been told about. These included accident, incident, medication and care records. We also spoke with staff and the manager. We found a combination of incidents and accidents that had occurred in April 2010. The records also showed us that medication errors had been recorded. Included in these were incidents where people had been admitted to hospital through their declining health, which indicates illness rather then accidents. The manager of the home had taken steps to address the medication errors which included an audit system which was working well. The manager told us this is why they were able to tell us when any incidents, medication errors or accidents had occurred and taken the appropriate action more quickly. We looked at all the accidents records 35 in total for the month of April. Although the appropriate action had been taken the records did not demonstrate how the home monitors people when they have had a fall for a few days after the fall to ensure no further injuries develop. For example a person had a fall, with another one shortly after, the accidents records said found on floor no injury previous injuries apparent. When looking in the care files for this person there was no information to say what the previous injuries were. This means staff can not track back to identify if new injuries have occurred when a person has a fall again. In one incident record we found an entry that said the staff member had noticed a large bruise on a persons leg, while assisting them with personal care. This was reported and shown to the team leader. We looked at the persons care file and no follow up action had been taken. Two months previous to this the doctor had visited the person for another reason, and was asked by staff about some bruising present at that time. The doctor had said he was not concerned about this. The home failed to act in respect of the new bruising that had appeared because of the doctors comments previously. This means staff had become complacent and there was a possibility of abuse going un unnoticed . We shared our concerns with the manager, who told us that she would speak with team leaders about reporting incidents where new injuries have appeared. We looked at information contained in the report that is completed by the area manager each month. We found no reference to the accidents or medication errors apart from one. Care Homes for Older People Page 4 of 9 The following observation were made by the pharmacy inspector: The pharmacist inspection lasted three hours. The reason for the inspection was to check compliance with the regulations surrounding the safe handling of medicines due to a number of medicine errors reported by the home to the Commission. Seven peoples medicines were looked at, together with their Medicines Administration Record (MAR) charts and care plans. Two team leaders were spoken with and all feedback was given to the registered manager. The medicines were stored in two medicine trolleys which were used to transport the medicines to the people in the home. These were kept in two dedicated medicine rooms. Surplus medicines were kept in a locked cabinet and all Controlled Drugs were kept in a separate locked cabinet. These were all clean, tidy and well organised to enable staff to easily see each persons medicines, reducing the risk of potential errors. The home does see all the prescriptions prior to dispensing but these were not readily available to check with the MAR charts during the inspection and hence not available for other staff to use to check the MAR charts. The quantities of all medicines and any balances carried over had been recorded enabling audits to take place. These indicated that the majority of medicines had been administered as prescribed and records reflected practice. Most of the errors seen had previously been identified and the team leaders had taken appropriate action to rectify them. The home had installed a good quality assurance system to identify medicine errors. This had lead to an increase in reporting of medicine errors to the commission, and systems had been introduced to reduce the risk of further errors. The care plans listed some of the clinical conditions of the people. Whilst this would enable care staff to support some of the peoples clinical needs, without all the information they would not be able to look after them as well as they might. The majority of the external health care professional visits had been recorded and it was possible to track why a doctor had been called and the outcome of the visit, for example, why a dose had changed. One person had been prescribed an injection to be administered by the district nurse on a three monthly basis. Staff had failed to notice that this had not been administered despite being recorded on the MAR chart. There was no record of any health care professional visits or any other evidence to demonstrate when it was due to be or had been administered. The manager had addressed this situation following the inspection and immediately implemented a new system to prevent similar errors occurring. This was commended. One team leader spoken with had a very limited knowledge of the medicines she administered. She would not be able to fully support the peoples clinical needs without such knowledge. Medicine information books were available to read about what each medicine was for though. What the care home does well: Accidents and incidences are reported to us and where required other health care Care Homes for Older People Page 5 of 9 professionals are involved. The home has developed a good auditing system to ensure the administering of medication is regularly audited and where errors are identified reported immediately. 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 6 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 7 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 18 13 Unexplained injuries must be 31/05/2010 investigated. This will ensure people are safeguarded and protected from harm. 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 13 Further training in the indications and side effects of medicines is advised to enable staff to fully support the clinical needs of the people in the home. It is recommended that the photocopy of the prescription is kept alongside the MAR chart for reference. 2 13 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. 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