Care Home: Stibbs House

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What the care home does well This inspection looked at the handling of medicines in the home and did not look at other areas of care. What the care home could do better: Action must be taken to ensure that staff give medicines from the labelled container supplied by the pharmacy or dispensary. Information about medicines to be given must be consistent, up to date and have clear dose instructions. This is to ensure that the correct medicines are always given and people`s health is protected. Action must be taken to ensure that storage for controlled drugs meets the Misuse of Drugs (safe custody) regulations 1973. It is recommended that regulation 37 notices sent to CQC reporting medicine errors provide more information about steps taken to protect the person`s health and any action taken to prevent a similar mistake happening again. Random inspection report Care homes for adults (18-65 years) Name: Address: Stibbs House 74 Stibbs Hill St George Bristol BS5 8NA 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: Sue Fuller Date: 2 9 0 6 2 0 1 0 Information about the care home Name of care home: Address: Stibbs House 74 Stibbs Hill St George Bristol BS5 8NA 01179619137 01179476786 Telephone number: Fax number: Email address: Provider web address: admin@aspectsandmilestones.org.uk Name of registered provider(s): Name of registered manager (if applicable) Miss Cheryl Christine Anstey Type of registration: Number of places registered: Conditions of registration: Category(ies) : Aspects and Milestones Trust care home 10 Number of places (if applicable): Under 65 Over 65 0 0 learning disability physical disability Conditions of registration: 10 10 10 Adults with learning disabilities which may include those with physical disabilities Manager must be a RN on parts 5 or 14 of the NMC register Date of last inspection Brief description of the care home Stibbs House is one of the services operated by Aspects and Milestones Trust. It is a registered care home with nursing offering respite care for up to 10 people who have learning disabilities, in particular those who have profound multiple disabilities. The majority of service users are in need of nursing care. The care staff are experienced in this type of care and are led by a team of Registered Nurses. Care Homes for Adults (18-65 years) Page 2 of 9 Brief description of the care home The house is situated in a suburban area and is easily accessible by car or bus. There is easy access to local shops and community facilities. Stibbs House is a modern purpose built home. There are 10 single rooms on two floors accessible by a lift. There are two lounges, a dining room and a multi sensory room. There is a large secure garden and patio to the rear of the home. Care Homes for Adults (18-65 years) Page 3 of 9 What we found: The pharmacist inspector carried out this inspection following concerns raised about the handling of medicines in the home. We (the Care Quality Commission) spoke to staff on duty and looked at the policies and procedures in place for handling medicines. We looked at the medicines brought in by the people currently using the service and the records that have been made about their medicines, as well as the care records for two people. We also looked at the arrangements for storing medicines. We looked at the records kept in the home concerning three mistakes we have been told about, when medicines had been given incorrectly. One person had not been given a dose of their lunchtime medicine. On two occasions another person was mistakenly given their emergency treatment for epilepsy instead of their medicine for constipation. One person had been given the wrong emergency treatment for epilepsy because staff were unaware that their care plan had been changed. The home had not told the Care Quality Commission (CQC) about the last of these mistakes and staff could not find any information in the home about any action taken. Staff told us that this mistake had been noticed by a community nurse so they had not reported it themselves. We found that, following medicine errors, insufficient information was available to show what action staff had taken to protect peoples health or to reduce the risk of similar mistakes happening in future. People using the service stay for a variable amount of time and bring in their own medicines for staff to administer. There is a policy in place to ensure that people bring the correct, current medicines, in the labelled container provided by the pharmacy. This is important so that staff can be confident they are giving medicines correctly. However when we checked the medicines currently being used we saw that one person had brought in a strip of tablets with no pharmacy label. Another person had two bottles of liquid medicines which had no pharmacy label with the persons name or the dosage instructions. Another person had tablets in a bottle with a label dated in 2008. This means that staff cannot check that they are giving the medicine correctly, as it has been prescribed. Further action is needed so that people can be confident that they will be given the correct medicines. An immediate requirement notice was left concerning this. A policy is in place for staff to receive information about peoples current medicines. We saw that this information was kept. In addition staff have produced an individual prescription sheet for each person. This lists the names of the persons medicines but does not include any information about the dose taken. The sheets are signed by the nurse completing them but are not dated and have no review date. In some cases different information was seen on the different records kept. This makes it difficult for staff to be clear about which information is correct and increases the risk of mistakes being made. Action is needed to ensure that the information kept is consistent, up to date, and has sufficient detail. Staff produce printed medicines administration record sheets for each person. These are signed when medicines are given. The sheets are also used to record the amounts of medicines received into the home, a running stock balance and the amount returned to the person when they leave. This means that there is a clear audit trail of medicines used in the home so that staff can check that they have been used correctly. We saw that Care Homes for Adults (18-65 years) Page 4 of 9 occasionally the amount of medicine returned had not been recorded. These records must always be completed to give an accurate audit trail. Secure storage is available for medicines. A medicine fridge is available. The temperature of the fridge should be recorded daily but we saw several gaps in the record. Staff should ensure this is checked and recorded daily. Storage is provided for controlled drugs, which need additional security. However this does not appear to meet the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973. Action must be taken to ensure that the storage arrangements for these medicines meet legal requirements. A suitable register is available to record the safe use of these medicines. 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 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 9 13(4) All people using the service 07/05/2008 must have any potential risks to them assessed and recorded. This will promote their welfare and safety. 2 23 13(6)13(7) The home must ensure clear 07/05/2008 reactive strategies and risk assessments are put in place for all service users who present behaviour, which challenges the service. This will promote their welfare and safety. Care Homes for Adults (18-65 years) 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 1 20 13 Action must be taken to 10/07/2010 ensure that medicines are brought into the home in the original labelled container supplied by the pharmacy. Information about peoples medicines must be consistent, up to date and correct So that people using this service can be confident that they will be given their medicines correctly and safely 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 20 13 Action must be taken to 16/08/2010 ensure that storage used for controlled drugs meets the requirements of the Misuse of Drugs (Safe Custody) regulations 1973 To meet legal requirements on the storage of these medicines. 2 20 13 Systems in place must 16/08/2010 ensure that information kept about peoples medicines, including the medicines administration record sheet, is consistent, accurate and Page 7 of 9 Care Homes for Adults (18-65 years) 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 up to date. Prescribed medicines must be given from the persons own, labelled container . To make sure that people are given their medicines correctly. 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 20 It is recommended that notices sent to CQC reporting medicine errors provide more information to show what steps have been taken to protect the persons health and whether any action has been taken to prevent further mistakes. This would show that the home has taken action to minimise any harm to people using the service. Care Homes for Adults (18-65 years) 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 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. 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