There is an injunction/gagging order on me personally (apparently, I have not been served or notified, but a verbal application was made in court yesterday 31st JAN 2014 by the official solicitor.
The judge whom will not be identified but in this instance be known as idiot, refused to deal with an urgent application by the client to have her son TL removed from NCP with immediate effect due to the fact (that is undeniable fact) that he is suffering a lack of care and is being mistreated to the point that his physical health has worsened drastically and his mental health is suffering.
The evidence for the court was clear, there is an transparent alignment between TL's physical condition worsening and the findings from the independent Inspector from the Care Quality Commision, over a 7 month period.
without publishing material that could lead to the identity of TL, here are links to the Care Quality Commision re NCP.
http://t.co/l176qTGJiP
now remember this is what they said in 2013:
What we have told the provider to do
We have asked the provider to send us a report by 10 September 2013, setting out the
action they will take to meet the standards. We will check to make sure that this action is
taken.
Where providers are not meeting essential standards, we have a range of enforcement
powers we can use to protect the health, safety and welfare of people who use this service
(and others, where appropriate). When we propose to take enforcement action, our
decision is open to challenge by the provider through a variety of internal and external
appeal processes. We will publish a further report on any action we take
after reading the report above - made in June 2013, take a look at the second report published in Jan 2014
http://www.cqc.org.uk/sites/default/files/media/reports/1-119324988_New_Court_Place_INS1-900941855_Responsive_-_Follow_Up_14-01-2014.pdf
What we have told the provider to do
We have asked the provider to send us a report by 25 January 2014, setting out the action
they will take to meet the standards. We will check to make sure that this action is taken.| Inspection Report | New Court Place | January 2014 www.cqc.org.uk 5
Where providers are not meeting essential standards, we have a range of enforcement
powers we can use to protect the health, safety and welfare of people who use this service
(and others, where appropriate). When we propose to take enforcement action, our
decision is open to challenge by the provider through a variety of internal and external
appeal processes. We will publish a further report on any action we take.
here are some snippets that should have you asking - how is this care home aloud to continue to run?
When we had inspected New Court place on 24 July 2013, we found that people's care
plans did not reflect the needs of the person and that key information and risk
assessments had not been completed.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
During our inspection on 16 December 2013, we found that the provider had carried out a
review of all the care plans which were held electronically including their risk assessments.
We were told by the manager that manual care plans were now available for each person
which the 'agency' staff were able to access or could be used in the event of a system
failure. We were also told that each care plan had been reviewed monthly by the care staff
and any changes in people's needs had been updated and always added to the manual
care plans. When we reviewed both the electronic and the paper care plans, we noted that
in all the paper care plans the information was three months behind.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
This meant that although the provider had
updated the electronic care plans and risk assessments, people were still at risk of
receiving inappropriate care because some staff were working from paper care plans that
were three months out of date.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
We saw from people's care plans that each person had an individual activity plan available
and that a group activity chart had been displayed on the notice board. The manager said
that they had recently re–decorated the activity room and people had access to computers
and games. However, we noted from one person's care plan which stated that they had | Inspection Report | New Court Place | January 2014 www.cqc.org.uk 7
'computer' as an activity for the morning of our inspection. We observed during our
inspection that there were no formal activities taking place in the home. We noted that the
person who had 'computer' as their activity for the morning was in the activity room but all
computers had been switched off with no staff present and no activities being conducted.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
We noted in the main communal lounge/dining room that people were moving around
freely but that there was little staff interaction with people except during lunch time when
staff were at hand to assist people with their meals. Again, we noted that staff did not
interact with people whilst feeding them. We observed that one person we knew to have
the capacity to communicate verbally was being fed by a staff member but the staff
member did not interact with the person, nor did they wipe the person's mouth whilst
feeding them. This meant that people were not treated with dignity and respect.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
The manager told us that they did not have an emergency kit either in the home or their
vehicles at present and that they were in the process of bagging items to be placed in the
kit. This meant that the provider did not have arrangements in place to deal with
foreseeable emergencies.
Management of medicines Action needed
People should be given the medicines they need when they need them, and in a
safe way
Our judgement
The provider was not meeting this standard.
People were not protected against the risks associated with medicines because the
provider had inappropriate arrangements in place to manage medicines.
We have judged that this has a moderate impact on people who use the service, and have
told the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
During our last inspection on 24 July 2013, we had found that the provider was not
meeting this standard because there were inadequate systems in place to manage
medicines safely.
During this inspection, we found that the provider had made changes to improve on the
existing systems. The manager told us that daily audit of all medicines and other checks
had been carried out since the last inspection. However, they were unable to locate the
audit reports.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
Currently, there was one individual who had been assessed as being able to self-
medicate. We spoke with the person and they were able to explain to us about the
medicines, the reason for them taking it and how often to take them. We noted that the
medicines for this person were kept in their room in a locked cabinet. This meant that
medicines had been stored safely. However, a risk assessment for this person's medicines
and its management had not been carried out to ensure that identified risks were
minimised and managed appropriately.
The staff we spoke with said that medicines were ordered monthly and were dispensed by
the local pharmacy. We saw that all prescribed medicines had been stored safely in locked
medicine trolleys, in medicine cabinets which in turn had been kept locked in the medicine
room to ensure that all medicines were stored appropriately and safely.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
We also noted from the medicine administration record (MAR) charts that medicines had
been signed for when given. However, the provider may find it useful to note that staff had
inappropriately marked these sheets with crosses next to the prescribed labels which
could be interpreted as discontinued. We noted for one person who required their
medicines every three day, again the staff had circled the dates that the medication should
be given. When marking the MAR sheet, it appeared that the wrong dates had been
highlighted, therefore instructing the medicines to be given on the wrong dates. We also
noted that where handwritten instructions had been made on the MAR sheet, this had not
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
been signed by two staff and that the dose of the medicine had not been identified. This
meant that the systems were not robust enough to safeguard any errors happening. It also
demonstrated that the audit system that the manager had told us that had been put in
place had been ineffective.
We noted that a record of the room temperature where medicines had been stored had
been kept so that the temperature was monitored to ensure that all medicines were stored
at the recommended temperature to maintain their effectiveness. However, the provider
may find it useful to note that the record for the room temperature had not been recorded
each day. The record for the month of December 2013 showed that in the last week, four
days had been missed.
The staff we spoke with said that currently there were no controlled drugs prescribed for
any people using the service. However, we noted that there was a system for the storing
and recording of controlled drugs as required by legislation.
There was a safe system for the disposal of medicines that were no longer required and
records of all medicines that had been disposed of had been kept so as to maintain an
audit trail.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
Action we have told the provider to take
Compliance actions
The table below shows the essential standards of quality and safety that were not being
met. The provider must send CQC a report that says what action they are going to take to
meet these essential standards.
Regulated activities Regulation
Accommodation for
persons who require
nursing or personal
care
Treatment of
disease, disorder or
injury
Regulation 9 HSCA 2008 (Regulated Activities) Regulations
2010
Care and welfare of people who use services
How the regulation was not being met:
The provider was not meeting this standard because the
provider had not taken the appropriate steps to ensure that each
service user was protected against the risks of inappropriate
care or treatment. Regulation 9(1)
Regulated activities Regulation
Accommodation for
persons who require
nursing or personal
care
Diagnostic and
screening
procedures
Treatment of
disease, disorder or
injury
Regulation 13 HSCA 2008 (Regulated Activities) Regulations
2010
Management of medicines
How the regulation was not being met:
The provider was not meeting this standard because; service
users were not protected against the risks associated with the
unsafe use and management of medication. Regulation 13
This report is requested under regulation 10(3) of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2010.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
the thing is that followed this report, leaving the question - why was this home not closed?????
Our judgement
The provider was not meeting this standard.
People did not experience care, treatment and support that met their needs and protected
their rights.
We have judged that this has a minor impact on people who use the service, and have told
the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
We reviewed the electronic care plans for people who used the service. We saw evidence
that people's needs had been assessed before they had been admitted to the home.
However, we noted from the care plans that some people had not had risk assessments
carried out. For example, one person who had diabetes, but there was no guidance for
staff on the signs and symptoms they should watch out for. This meant that people with
this condition would be potentially at risk if help was not sought immediately when they
became hypoglycaemic.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
We saw that the care plans contained sections for assessments such as 'bathing,
dressing, activities and resident profiles. We did however note that the information
provided in the care plans was not consistent and in some cases was either missing or
was in the wrong place. For example, we saw in the 'activities' section, days had been
ticked to indicate that a person was out of the home on a Tuesday but when we checked
the persons daily notes that person had not been out of the home or participated in any
activities.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
We also saw that under peoples profiles some information for example, medical history,
life history, or behaviours was noted and that in others is was not available or in a different
section.
The staff we spoke with said that the 'agency' staff did not have access to the electronic
care plans which meant that permanent staff had to provide 'on the job' training and
discussed people care needs verbally rather than referring to the care plans. We were also
told that because of this staff felt that they were 'workers rather than carers' because they
were more task orientated and were unable to interact with people as they should.
This meant that people may not have received appropriate care and treatment.
The deputy manager stated that two people attended the day centre and another went to
the local college. We observed that two people were using the computer and others were | Inspection Report | New Court Place | August 2013 www.cqc.org.uk 8
either resting or listening to music in their rooms.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
Some people were wheeling their
wheelchairs around the corridors, trying to get the attention of staff. The staff we spoke
with said that people were left to decide what they wanted to do. There were no planned
activities. This meant in practice that people were not encouraged to pursue meaningful
activities to maintain their welfare and to promote their wellbeing.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
Reasons for our judgement
The home had a system for the management and administration of medicines. The
majority of prescribed medicines were dispensed by the pharmacy in blister packs.
We checked the Medication Administration Record (MAR) charts and noted that the MAR
for one person was signed to indicate that the prescribed medicines had been given. We
found that this was incorrect since the doses prescribed to be given in the morning and
lunchtime of 23 July 2013 were still in the blister pack.
We found that a medicine that was prescribed to be taken daily for 28 days had not been
given since 20 July 2013. The deputy manager said that the doctor had told them to give
the medicine daily for three weeks only and then discontinue it, but there were no written
instructions to this effect.
In another case, we found that the MAR chart had been signed daily to indicate that a
prescribed medicine had been given. We noted that the date the medicine container was
opened was 24 June 2013 and the number of tablets prescribed was 28. However, on the
day of our inspection, 24 July 2013, there were 25 tablets left in the container, when none
should remain. This meant that staff had been signing the MAR charts without giving the
medicine.
We noted from the temperature record sheets that, since 15 July 2013, the room
temperature had always been higher than 25°C. This meant that medicines had not been
stored at the manufacturers' recommended temperature, which may have compromised
their effectiveness.
We further noted that there was a bottle of Paracetamol being stored as belonging to the
home. The records showed that there were 64 tablets left on 25 May 2013. On the day of
our inspection there were 20 tablets remaining. It was not clear to whom these tablets had
been given. Therefore people using the service had been placed at risk of being given
medicines that had not been prescribed.
Currently, there were no controlled drugs in use. We noted that medicines no longer
required had been returned to the pharmacy for disposal and appropriate records had
been maintained.
The inaccurate recording, the lack of written instructions and the omission in the
administration of medicines had placed people at risk of inappropriate care and treatment.
no problems or concerns for Northampton County Council Social Workers, not even a peep from them, this must be normal care in their opinion. The Official Solicitor is quite happy for this "kind of" care.
