Archived: Custom House

Updated 5 February 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We undertook an unannounced focused inspection of Custom House on 8 January 2016. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our 15 and 16 September 2015 inspection had been made. The team inspected the service against two of the five questions we ask about services: is the service safe and is the service well-led.

The inspection team consisted of one inspector.

As this was a focussed inspection to follow up previous breaches of regulations we did not request provider information return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. Before the inspection we reviewed the information we held about the home and the action plan sent to us by the provider. We also received a copy of a report provided by the local NHS pharmacy advisor.

We spoke with the registered manager, one care worker and one person about how they managed their medicines. We inspected the property and reviewed documents related to the previous breaches including medicine administration records, care records, risk assessment documents and quality monitoring and audit documentation.

Updated 5 February 2016

We carried out an unannounced comprehensive inspection of this service on 15 and 16 September 2015, at which two breaches of legal requirements were found. These were related to the safe and effective administration of medicines, limited general risk assessments being in place linked to the delivery of care and a lack of effective governance processes at the home. We took enforcement action against the provider and the registered manager in relation to the safe management of medicines and lack of risk assessments. We set a compliance action in relation to the lack of effective governance arrangements.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook a focused inspection on 8 January 2016 to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Custom House’ on our website at www.cqc.org.uk’

Custom House is the only residential establishment run by Blyth Star Enterprises. Blyth Star also operates an outreach service from the same building, which is not regulated by the Commission, because this is outside the scope of the regulations; because this arm of the service does not deliver personal care to people who use it. It also runs a number of work placements and day facilities.

Custom House provides accommodation for up to seven people with mental health issues, who require assistance with personal care and support. People living at the service have their own apartments, which include bathing facilities and a small kitchen area. They also have access to communal facilities. At the time of this inspection there were five people living at the service.

The home had a registered manager who had been registered since November 2013. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had engaged with the local NHS pharmacy advisor, who had undertaken a comprehensive review of how medicines were managed at the home and made recommendations to improve the administration process. The provider had implemented these recommendations and made significant changes to how medicines were handled at the home. New medicine administration records (MARs) had been introduced which gave full details of the medicines people were receiving. Specific care plans related to the administration of “as required” medicines had been developed and plans and risk assessments were in place to support people who managed their own medicines. Medicines were stored safely in locked cabinets or boxes in fridges. The provider had appointed a specific member of staff to order, monitor and check the appropriate management of medicines at the home.

New risk assessment processes had been developed which covered any risks associated with people’s individual care, along with wider environmental risk issues. The manager also showed us additional person centred quality monitoring systems that had been developed. These were based around each individual person living at the home. They covered reviews of care, care records and associated items of risks, such as monitoring electrical appliances in people’s rooms and other environmental factors. These checks were carried out on a rolling three monthly programme and were in addition to the more general checks and audits undertaken at the home. Actions and quality reports were also now reviewed by the provider’s board or quality assurance group.

At our focused inspection on 8 January 2016, we found that the provider had met the requirements of the warning notice, followed their action plan and met legal requirements.