Care Home: Tudor Care Home

What the care home does well We found no significant examples of good practice when handling medicines. What the care home could do better: Records of medicines received, given to people and disposed of must be clear, accurate and complete so that all medicines can be fully accounted for. Medicines must be given to people correctly because receiving them at the wrong time, wrong dose or not at all can seriously affect their health and wellbeing. There must be sufficient information in people`s care plans to help make sure their medicines are given to them correctly. Regular checks (audits) on the medicines stock and records must be carried out to help make sure people`s medicines are being handled safely. Staff must be competent when giving and recording medicines and this must be regularly reviewed to make sure they have the necessary skills to do it safely. Inspecting for better lives Random inspection report Care homes for older people Name: Address: Tudor Care Home 62 Orchard Road St Annes Lytham St Annes Lancashire FY8 1PJ The quality rating for this care home is: The rating was made on: new service which has yet to be given a quality rating 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 assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. 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: Stephanie West Date: 0 2 0 1 2 0 0 9 Information about the care home Name of care home: Address: Tudor Care Home 62 Orchard Road St Annes Lytham St Annes Lancashire FY8 1PJ 01257453272 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Ms Michelle Bernadette Beattie care home 18 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia 18 Over 65 0 Conditions of registration: The registered person may provide the following category of service only: Care home only - Code PC To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of people who can be accommodated is: 18. Date of last inspection Brief description of the care home Care Homes for Older People Page 2 of 8 What we found: We visited the home because we found shortfalls in the way medicines were handled at a recent key inspection. The visit was carried out by Simon Hill, Pharmacist Inspector. It lasted approximately five hours and involved speaking with the manager and two carers. We checked a sample of medicines stocks, medicines records and care plans and observed part of the morning medicines round. We gave detailed feedback to the manager at the end of the visit. Overall we found some serious shortfalls when handling medicines that could affect the health and wellbeing of people who live in the home. We checked a sample of medicines records and stock and found most medicines difficult to account for as there was no clear system of stock control in place. New supplies of medicines were not always recorded on receipt and when stock was left over at the end of the month it was not carried forward. We carried out some random checks of boxed medicines and found that some did not add up correctly, which showed they had been occasionally missed. Some people had missed doses of antibiotics and two people had received the wrong dose of their medicines on several occasions, one for anxiety and another used for controlling blood pressure. Missing medicines or receiving the wrong dose can seriously affect a persons health and wellbeing. We looked at the times medicines were given and found the records did not always state the correct time to take them in relation to food intake. Two different carers both confirmed that some medicines were being given at the wrong time notably medicines that should be given before food were being given after. Giving medicines at the wrong time can stop them working properly. We checked how people were supported when they did not want to take their medicines. The key code on the records was not always used correctly to explain why medicines had not been given and we saw some gaps when staff had forgotten to make any record. We checked several peoples care plans when they were regularly refusing to take their medicines. We found no information to say how they were to be supported and what actions had been taken such as contacting their GP to make sure their medicines and general health were properly reviewed. We saw no formal recorded checks of the medicines stock and records that meant mistakes were not being found and acted upon to help prevent them happening again. All staff had attended formal medicines handling training in the past but the manager said that none had been observed when giving out medicines to make sure they were doing it properly. Medicines training, competency assessment and medicines audits need to be detailed and repeated regularly to help make sure staff have the necessary skills to handle medicines safely. We looked at a sample of care plans and records to check if medicines and peoples health care needs were properly reflected in them. We saw no formal system for recording information about how when required medicines were to be given. We saw two people currently taking when required medicines for anxiety and several others taking when required laxatives and pain relief but there was no information about Care Homes for Older People Page 3 of 8 how and when they should be given. One person that was regularly agitated and sometimes aggressive had no information in their care plan about how staff were to support them through these periods. Having clear written care plans helps make sure people get their medicines when they need them and helps make sure they receive the right amount of support to keep them safe. We looked at how medicines were stored and found they were kept safe. The manager said she had recently cleaned and cleared out stock to try and tidy it up. However, the last available records of medicines disposal were dated three months ago and no other records could be found. Having accurate records of medicines disposal helps makes sure they can be fully accounted for. 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 4 of 8 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 5 of 8 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, Care Homes 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 24 Regular checks (audits) on the medicines stock and records must be carried out. This will help make sure medicines are handled safely. 06/02/2009 2 9 18 Staff must be competent and 06/02/2009 have the necessary skills when giving and recording medicines. This will make sure people have their medicines given to them correctly. 3 9 13 Medicines must be given to people correctly as prescribed. Because getting medicines at the wrong time, wrong dose or not at all can seriously affect a persons health and wellbeing. 06/02/2009 4 9 13 There must be sufficient information in peoples care plans about how to give medicines. This will help make sure they 06/02/2009 Care Homes for Older People Page 6 of 8 are always given correctly. 5 9 13 Records of medicines 06/02/2009 received, given to people and disposed of must be clear, accurate and complete. This will help make sure they are fully accounted for and handled safely. 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 7 of 8 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI 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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