Our Action Plan following CQC Inspection 07/12/22

Action Plan following CQC Inspection 7th December 2022

1. Using Medicines Safely:
i. Purchase and install secure cabinets in each bedroom to enable the safe storage of creams and any other medication related item suitable for storing in such a location.
ii. As part of the new auditing system, the registered manager and assistant manager will carry out regular checks to ensure all medicines, creams, ointments and drops etc. are correctly dated and disposed of upon expiry. Room temperatures will now be routinely monitored to ensure all products are stored within the correct temperature parameters.
iii. Work with Boots to purchase the eMAR system. This is an electronic medication system to facilitate staff in dispensing and recording medication accurately, therefore removing the need for the current high volume of mental arithmetic, so mitigating the risk of human error.
This system records administration accurately and sends alerts when medication is missed.
This medication management solution is a safe, accurate and highly efficient way to optimise the delivery of the medication to be administered in our Home. It also ensures for comprehensive recording of all care meds given, and the ordering of medication into Alandale.
iv. Additional competency training for all senior staff handling medication, to ensure they understand the procedures involved thereby facilitating accuracy and consistency at all times.

2. Accidents & Incidents (learning lessons when things go wrong)
i. Following review, the reporting and recording of accidents & incidents has been streamlined and the checking of these records has been incorporated into the new auditing system. The reason for doing this is to simplify the process for staff therefore reducing the risk of errors.
ii. In addition to the comprehensive logging of accidents & incidents that enables management to take appropriate action, the new auditing system will enable the registered manager to provide evidence that they have taken such action.

3. Assessing Risk, Safety Monitoring & Management
i. As part of the new auditing system, the registered manager will routinely spot check staff recording & reporting to ensure this is consistent and accurate.
ii. The registered manager has reviewed and expanded care plans where required to provide more detailed guidance to staff in relation to high-risk areas such as choking, falls, catheter care etc. Information will now include dates clearly stating when reviews have taken place and action taken. As a consequence, staff will be more knowledgeable and have greater understanding in how to both prevent and manage high risk situations.
iii. The registered provider has used a contractor to replace the mixer valve in question to bring the water temperature within the appropriate parameter and this action has been recorded on the current monitoring system. All maintenance checks will be audited under the new system that has recently been introduced. As a consequence, all mixer valves provide water at an appropriate temperature and the more thorough auditing system will ensure maintenance issues identified will be addressed and rectified appropriately.

4. Preventing and Controlling Infection
i. In addition to the racks of PPE available outside every bedroom and in every corridor in the Home, the lidded bins have been replaced with pedal bins. The lid of the bin can now be raised using the foot therefore reducing the risk of cross contamination.
ii. The bath hoist with rust marks has in the short term been painted with an enamel product. This will be replaced. This will achieve an upgrade as required.

I am pleased to confirm that we have now completed all of the above. The new electronic medication system is fully operational and is working exceptionally well with a lot of positive feedback from staff, residents and representatives. The new bath with integral hoist looks fantastic and is working extremely well as part of the new refurbished bath and hairdressing room. The auditing system is also proving effective, facilitating the review cycle within the Home, so enabling the quality of our service  to be continually improved. 

Paul Maple – Registered Provider.