Application Incomplete by srH59X9


									                                                           CQC HSCA Compliance
                                                           Newcastle upon Tyne
Mr. Paul Lynch                                             NE1 4PA
CLS Care Services Limited                                  Telephone: 03000 616161
Central Office, Pepper House                               Fax: 03000 616172
Market Street

19th August 2011

Care Quality Commission
Health and Social Care Act 2008
Factual accuracy check

Reference number: 1-282626629

Dear Mr. Lynch

Following your recent review of compliance, I attach a copy of our draft report.

If you have any comments relating to factual inaccuracy in the report, please collate
them and submit one response within 14 working days. You can record your
comments on the factual accuracy form attached.

We will review your comments and incorporate them into the report if appropriate or
relevant. If your comments are not accepted, we will explain why. If we do not receive
any comments from you by the date specified above, we will finalise the report and
publish it on our website.

If you have any questions about this letter, please contact us through our National
Contact Centre using the details below:

Telephone: 03000 616161


Write to:    CQC HSCA Compliance
             Newcastle upon Tyne
             NE1 4PA
If you do get in touch, please make sure you quote or have the reference number
(above) to hand. It may cause delay if you are not able to give it to us.

Yours sincerely

Kathleen Byrne
Compliance Inspector
Factual accuracy comments log for a review of compliance
Please fill in all parts of this form and return to or
CQC HSCA Compliance, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA

Reference number:                      1-282626629 Lyndhurst
Provider name:                         CLS Care Services Limited
Provider address:                      Central Office, Pepper House, Market Street,
                                       Nantwich, Cheshire, CW5 5DQ

   Page     Outcome                                         CQC    CQC comments
  number                   Suggested changes with         decision   e.g. explanation of
                                explanation                                decision
 e.g. Pg
    4                     e.g. change last sentence        or X
                            from 10 staff to 15 staff
 06-07      09           1.
                         The statement – ‘We saw
                         that the medication trolleys
                         were left unlocked when
                         staff took medicines to
                         people. This was because
                         the Manager had the keys.
                         It was agreed that their use
                         in public places would be
                         risk assessed’ is incorrect.

                         The staff always keep the
                         trolley within sight to
                         ensure safety.

                         The Manager had hold of
                         the keys this particular day
                         to gain access to the
                         stationary cupboard. The
                         senior staff hold the keys
                         at all times.

                         There is no risk
                         assessment needed as the
                         trolley is in the control of
                         and observed by staff at all

                         Therefore we request this
                         statement be removed or
                         to have added the
                         following ‘but always keep
                         the trolley within their sight
to ensure safety’.

The statement ‘The lock on
one the trolleys was
broken but staff told us that
arrangements had been
made for it to be repaired’
is felt to be mis-leading.

The lock on the trolley can
be a bit temperamental but
it was still able to be
locked. Also when trolleys
are not in use they are
stored in a locked room.
Therefore we request this
statement be removed or
amended to read – ‘The
lock on one the trolleys
was broken but could still
be locked. Staff told us
that arrangements had
been made for it to be
repaired or the trolley to be
We are extremely
concerned by the
statement – ‘The controlled
drug cupboard (for
medicines liable to abuse)
did not meet current
specifications. The
Manager said that one
would be ordered’.

Firstly why is it considered
necessary to include the
statement in brackets
referring to medicines
liable to abuse? This is felt
to be overly emotive,
unnecessarily evocative
and out of context. This is
a care home with
extensive safety measures
which is continually
maned, not a street corner
pharmacist in a deprived
area liable to ram raiding!
We feel it is reasonable to
ask for an explanation as
to why it is felt that the
cupboard does not meet
current specification.
Please include reference
to legislation as it has been
inspected on numerous
occasions and always
been given a clean bill of
health. Therefore we do
not feel it is reasonable to
be expected to go to the
cost of purchasing a new
cupboard without clear
explanation based on
legislative requirements.
Otherwise we request that
the reference be removed.
It should also be
recognised drug cupboard
is situated in a locked
We would also appreciate
an explanation as to why it
was considered necessary
to make reference to the
‘medicines that had not
been disposed of after the
death of the person for
whom they were
prescribed’. These were
being safely and
appropriately stored in the
controlled drug cupboard
awaiting collection by our
supplying pharmacy.
Therefore we believe the
reference is both
superfluous and gratuitous
and should be removed.

With regards to the skin
patches being kept in 1
box, this was an oversight
by senior staff and actions
have been taken to
address this. The patches
have been separated.
All senior staff has been
reminded of the need to
store medication correctly.

In regard to the incorrect
date of administration of a
skin patch to which you
make reference. We are
unclear as to who this
refers to and would
appreciate more details to
enable a thorough check to
be carried out.
Gill what about the bottle
of liquid medicine? Its
point 7 in my email.

In regard to the reference
to the temperature of the
medicine room and
refrigerator. We believe
the statement is
unreasonable and
unnecessary as surely the
matter of importance is
that the temperatures are
being taken and recorded.
We do not believe that the
matter is of relevance to
the commission and given
the statement contains a
connotation of criticism ask
that it be removed.
For information the method
of recording is a room
thermometer and a fridge

The statement referring to
the contents of the
refrigerator making it
“difficult for air to circulate
and maintain an even
temperature” is a matter or
supposition and opinion
and as such should be
removed from the report or
as a minimum the report
should be amended to
include the following - “The
manager has confirmed
that the medicines not
requiring refrigeration and
for residents who have left
the home have been
In regard to the
unidentified tablets loose in
the cupboard. We believe
that these had fallen out of
the refused/returned
medication bottle, this was
addressed on the day of
inspection and we request
the report be amended to
reflect this.
In regard to the date
expired homely remedies.
All homely remedies that
were date expired have
now been removed and
replaced. A system has
been put in place that
ensures that these dates
are checked on a monthly
basis to ensure that
medication has not
In regard to hand written
MAR charts and signing
MAR charts. All senior
staff has been re-trained to
ensure the correct
procedure is being carried
out and double checking of
MAR charts at the end of
every shift is now
In regard to prescribed
medication that was not
given. We are unsure who
this refers to and require
more information to be in a
position to carry out a
thorough investigation.
In regard to the loose
tablet on the trolley, tablet
in blister pack and
administering antibiotics.

All staff have been re-
trained to ensure they give
medication as prescribed
and to ensure that they are
recording accurately
including double checking
blister packs, dates and
signatures as required.
Gill as per my email
(penultimate point) we
need to address the issue
regarding – ‘When we
looked at the records of
administration of other
medicines we saw that all
the dates on one person’s
record were incorrect (one
day behind). Some
records showed a few
omitted records of
administration where the
medicine had been given
but not recorded’.
We do not believe the
statement regarding staff
not administering
medication due to the
person sleeping to be an
accurate reflection of the
care taken in ensuring
medicines are
administered. Therefore
we ask that the following
be included- ‘Staff are fully
aware of the importance of
giving medication at the
prescribed time. However,
when residents are
sleeping it is sometimes
delayed until they wake out
                           of recognition for their right
                           to have periods of
                           undisturbed time.
                           Nevertheless the member
                           of staff will always ensure
                           they return to administer
                           the medicine or pass the
                           requirement over to the
                           next senior member to

(Include additional rows if required)

 Completed by (name(s))         Gill Reynolds & Paul Lynch

 Position(s)                    Home Manager & Quality & Compliance Manager

 Date                           08.09.2011

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