Stormont Lodge Care Home Service Adults Kirk Wynd Blairgowrie PH10 6HN Telephone:

Transcription

1 Stormont Lodge Care Home Service Adults Kirk Wynd Blairgowrie PH10 6HN Telephone: Inspected by: Shona Adam Type of inspection: Unannounced Inspection completed on: 13 August 2013

2 Contents Page No Summary 3 1 About the service we inspected 4 2 How we inspected this service 6 3 The inspection 10 4 Other information 20 5 Summary of grades 21 6 Inspection and grading history 21 Service provided by: Balhousie Care Limited Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Shona Adam Telephone enquiries@careinspectorate.com Stormont Lodge, page 2 of 22

3 Summary This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change after this inspection following other regulatory activity. For example, if we have to take enforcement action to make the service improve, or if we investigate and agree with a complaint someone makes about the service. We gave the service these grades Quality of Care and Support 5 Very Good Quality of Environment 5 Very Good Quality of Staffing 5 Very Good Quality of Management and Leadership 5 Very Good What the service does well The service continues to promote the involvement of residents and relatives in a very meaningful way. Regular meetings are very well attended and continue to contribute positively to the development of the service. What the service could do better The service should continue to consider the development and use of alternative methods to gather the views of residents who have difficulties with communication. What the service has done since the last inspection The service had introduced daily pre lunch apéritif for all residents who wished to take part. Residents appeared to thoroughly enjoy this social occasion. Conclusion The service continues to provide a very good quality of care to residents in a friendly, welcoming and warm environment. Who did this inspection Shona Adam Stormont Lodge, page 3 of 22

4 1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Information about all care services is available on our website at This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April Requirements and recommendations If we are concerned about some aspect of a service, or think it could do more to improve, we may make a recommendation or requirement. A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service, but where failure to do so will not directly result in enforcement. Recommendations are based on the National Care Standards, relevant codes of practice and recognised good practice. A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reform (Scotland) Act 2010 and Regulations or Orders made under the Act or a condition of registration. Where there are breaches of Regulations, Orders or Conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Care Inspectorate. Stormont Lodge is a care home service for older people, owned by Balhousie Care Group. It is situated in the Perthshire town of Blairgowrie and is registered to provide care for a maximum of 32 residents. The house sits in its own grounds and has a large south-facing garden. Accommodation is provided on two floors and there is a passenger lift. The service aims to provide the highest possible care ensuring service users are treated with respect and dignity at all times. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 5 - Very Good Quality of Environment - Grade 5 - Very Good Quality of Staffing - Grade 5 - Very Good Quality of Management and Leadership - Grade 5 - Very Good Stormont Lodge, page 4 of 22

5 This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. Stormont Lodge, page 5 of 22

6 2 How we inspected this service The level of inspection we carried out In this service we carried out a low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection This report was written following an unannounced inspection that took place on Monday 22 July and Tuesday 13 August by Inspector Shona Adam. Alison Bavidge, was also present on the visit that took place on the 22 July. In this inspection evidence was gathered from various sources, including the relevant sections of policies, procedures, records and other documents, including; evidence from the service's most recent self assessment personal plans of people who use the service training records health and safety records accident and incident records complaints records Public Liability Insurance Certificate Certificate of registration Schedule of staffing questionnaires that had been requested, filled in and returned to the care service from people who use the service, their relatives or advocates and staff members discussions with various people, including: - the manager - care staff - the people who use the service - relatives and carers of people who use the service observing how staff work examining equipment and the environment Grading the service against quality themes and statements We inspect and grade elements of care that we call 'quality themes'. For example, one of the quality themes we might look at is 'Quality of care and support'. Under Stormont Lodge, page 6 of 22

7 each quality theme are 'quality statements' which describe what a service should be doing well for that theme. We grade how the service performs against the quality themes and statements. Details of what we found are in Section 3: The inspection Inspection report continued Inspection Focus Areas (IFAs) In any year we may decide on specific aspects of care to focus on during our inspections. These are extra checks we make on top of all the normal ones we make during inspection. We do this to gather information about the quality of these aspects of care on a national basis. Where we have examined an inspection focus area we will clearly identify it under the relevant quality statement. Fire safety issues We do not regulate fire safety. Local fire and rescue services are responsible for checking services. However, where significant fire safety issues become apparent, we will alert the relevant fire and rescue services so they may consider what action to take. You can find out more about care services' responsibilities for fire safety at Stormont Lodge, page 7 of 22

8 The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self assessment document from the service provider. We were satisfied with the way the service provider had completed this and with the relevant information they had given us for each of headings that we grade them under. The service provider identified what they thought they did well, some areas for development and any changes they had planned. The service provider told us how the people who used the care service had taken part in the self assessment process. Taking the views of people using the care service into account We spoke informally with five residents. They all told us that they were very happy and settled in the care home. One resident told us that 'staff are very helpful and friendly both day and night'. Taking carers' views into account We spoke with one visitor during the inspection visit. We also received four questionnaires that had been completed and returned to us by relatives. All indicated a high level of satisfaction with the quality of the service. Completed questionnaires contained the following comments; 'My (relative) is well looked after by caring staff at Stormont Lodge. Clothes are sometimes muddled due to the fact that when I first took (relative) there, one of the staff washed (relatives) clothes. However, I subsequently took more clothes and did not think to label them. (Relative) can go where they wish within the home but Stormont Lodge, page 8 of 22

9 cannot go outside alone for their own safety. Those mentally able can go in and out. I have no particular complaints about the running of the home. If I had, I would speak to the manager or one of the staff who are all very approachable. Any suggestions I have made about my relatives care have been taken seriously and acted upon'. 'I was less happy when (my relative) was more able to move around and walk. Then I wasn't sure there were enough staff or the right kind of activities. Now that (relatives) dementia is so advanced, I am happy that the care home are doing much that can be done for her. Excellent re meals and re continually ensuring (relative) is physically comfortable'. Stormont Lodge, page 9 of 22

10 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths We found that the service had a very good level of performance in relation to this statement. The service used a range of methods to seek the views of residents, relatives and carers. These included the following: Regular care reviews provided an opportunity for the manager and staff to seek comments, suggestions and views about the quality of the service they provided. We know this because review minutes contained written evidence of discussions that had taken place during the review process. Resident meetings We saw that regular meetings took place and topics such as menus were discussed. It was very evident that suggestions made by residents were listened to and implemented when appropriate. An example of this was the request to have Bread and Butter pudding on the menu more often. We saw that this was introduced and residents thoroughly enjoyed it. Pre lunch drinks had recently been introduced for residents. These were served in the upstairs lounge. We saw that there was a well stocked drinks trolley and residents told us that they really enjoyed this daily event. Relative meetings Stormont Lodge, page 10 of 22

11 Regular meetings also took place with relatives. We were impressed with the level of information that had been given by the service in relation to staffing levels and dependency assessments. It was clear that this information had been appreciated by relatives as it provided them with a good insight into how the service was staffed. The service had also sought input from the local dementia liaison nurse who attended a relatives meeting to give a talk about dementia. We thought that this was a very good idea, it was also very well received by the relatives who attended the meeting. The service had developed a newsletter which was sent to all residents and relatives. A variety of topics were covered in the newsletter such as: Fundraising Entertainment Pet Therapy The 'Freedom Coach' New Staff Staff Training Dates for the Diary Interview with a resident This provided relatives and residents with a very good level of information about the day-to-day goings on in the service. We saw that the noticeboard also provided information in the style of 'You Said' and 'We Did'. This meant that relatives and residents were able to see what action the service had taken following any suggestions and comments they had made. Photographs of residents enjoying a variety of social events brightened up the noticeboards. The manager told us that a number of residents had taken part in the 'Going For Gold' event that had recently been held in Perth. It was very clear from the photographs that residents had really enjoyed taking part in this event. The service had made significant efforts to develop links with the local community and the resources within it. A coach was available to book in advance which meant that residents could attend local community events. Overall we thought the involvement of residents and relatives was a significant strength within the service. Areas for improvement Inspection report continued The manager had identified the following areas for improvement in the completed self assessment; Stormont Lodge, page 11 of 22

12 'To continue to maintain strong links with service users and their families, using their feedback in a positive way to guide good practice'. 'Introduced a comments and suggestion book housed at front entrance, to continue to develop good communication and to share ideas developing the service'. 'We are improving the dining experience by offering an aperitif prior to lunch, increasing our snack menu and welcoming feedback'. 'Development of a newsletter involving relatives, residents and staff'. We found that the service had already implemented some of these areas with very good outcomes for residents. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths We identified that the service had a very good performance in relation to this statement. We examined a sample of residents' personal plans, observed care practices and spoke with some staff and residents. The personal plans that we looked at were seen to be very detailed and provided a very good level of information which meant that staff were able to provide care that was consistent and met the needs of each resident. It was obvious that the personal plans were working documents that provided a very good picture of each individual resident and their identified care needs. The service had developed positive relationships with the local primary healthcare team. It was very clear that where a need had been identified, the service was quick to make a referral to the most relevant healthcare professional, such as; Podiatrist Dentist Continence advisory service District nurse CPN Dietician Stormont Lodge, page 12 of 22

13 Audiology and Optical services. We saw that risk assessments for areas such as pressure area care, safety and nutrition had been carried out when required. We saw that these were reviewed and updated regularly. This was good practice and meant that the care staff were able to provide the care that was most current for each resident. We observed a mealtime and saw that the experience was made to be a very social and enjoyable occasion for staff. The chef was seen to be very knowledgeable about residents preferences and dietary needs. Staff were very attentive to residents eating and drinking needs and support was provided when needed. A daily menu was seen to be available on dining tables. We thought that this was good practice as it provided residents with a range of choices and it also provided a useful focus for discussion with staff. The food that was serviced was nicely presented and looked and smelt very appetising. Residents told us that the food was lovely and nothing was too much bother if they wanted something different from what was on offer. Medication administration records were examined and these were found to be in good order. The manager told us that the local GP practice carried out annual medication reviews. We thought that this was a significant strength within the service and we were pleased to hear that other practices had plans to also carry out these type of reviews. It was obvious that the staff on duty knew each residents likes and dislikes very well. We saw some very good examples of meaningful interactions between staff and residents. Residents appeared to be very settled and relaxed in their care environment and were supported by staff who displayed a very warm and caring approach. Areas for improvement The service should continue to monitor, review and evaluate the very good practice identified in this statement with a view to ongoing and continuous improvement. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Stormont Lodge, page 13 of 22

14 Quality Theme 2: Quality of Environment Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths Please see Quality Theme 1, Statement 1 for further information in relation to this statement. Areas for improvement Please see Quality Theme 1, Statement 1 for further information in relation to this statement. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths We found that the service had a very good level of performance in relation to this statement. Inspection of all communal areas found them to be clean and in a good state of repair. A variety of systems and processes were in place to ensure the safety and protection of residents. These included the following; Risk assessments were carried out on a regular basis. These included both the physical environment and individual risks that had been identified for each resident. We saw that and issues that had been identified had been addressed. These assessments were seen to be reviewed and updated when needs changed. Stormont Lodge, page 14 of 22

15 A Health and Safety committee had been set up and meetings took place every two months. Minutes of the meetings were seen to be displayed on noticeboards within the service. It was clear that any issues raised and discussed at the meetings were actioned upon where appropriate to do so. The service used a maintenance log to record faults and items which required to be repaired, fixed or replaced. We saw that these were dealt with by the maintenance team effectively and efficiently. A form was completed following all accidents and incidents. The manager informed us that these were examined by her and action was taken following any issues that had been highlighted in the completed forms We saw that specialist equipment was maintained appropriately. This included hoists and stand aids. We observed staff to use gloves, aprons, disposal bags and appropriately wash their hands between residents. Areas for improvement The manager identified the following area for improvement in the completed self assessment; 'Continue to update risk assessments and mandatory training for all staff'. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Stormont Lodge, page 15 of 22

16 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths Please see Quality Theme 1, Statement 1 for further information in relation to this statement. Areas for improvement Please see Quality Theme 1, Statement 1 for further information in relation to this statement. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths We found that the service had a very good performance in relation to this statement. We examined individual staff training records and the services training plan and found these to be very comprehensive. A detailed induction programme was seen to be in place for all new staff. mandatory training, SSSC codes of practice, legislation and the National Care Standards were all included within the programme. We thought that this was very good. A yearly training plan was in place which included both mandatory training and specific training undertaken by staff. A monthly training programme was also in place. We saw that a variety of topics were covered in training sessions, these included the following; Stormont Lodge, page 16 of 22

17 Personalisation in dementia Increasing awareness in dementia Pressure ulcer prevention Sensory deprivation awareness Person centred care Nutrition and health Diversity Safe handling of medicines Diabetes awareness Provision of activities in a care setting. We were pleased to see that good use had been made of the local health team. We saw that the dementia liaison nurse had provided training sessions to the service. We observed staff care practices during the two unannounced visits. It was very evident that staff had developed good relationships with residents. Regular staff meetings were held for all groups of staff. Agendas and minutes of meetings were widely available for all staff. Issues such as, 'moving forward and enhancing the service', 'documentation and consistency' and 'registration with the SSSC' were all discussed. A system for appraisal and formal supervision were also seen to be in place within the service. This provided the manager with the opportunity to identify staff training needs and also to praise good care practice where appropriate. A learning resource area had been set up within the service. Best practice guidance, and information was seen to be available for all staff. We were told that the area was well used by the staff team. Areas for improvement The manager identified the following area for improvement within the completed self assessment; 'Continue to identify training needs for staff through supervision'. 'Continue to source relevant training from external bodies'. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Stormont Lodge, page 17 of 22

18 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. Service strengths Please see Quality Theme 1, Statement 1 for further information in relation to this statement. Areas for improvement Please see Quality Theme 1, Statement 1 for further information in relation to this statement. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide. Service strengths We found that the service had a very good performance in relation to this statement. A wide range of systems, policies and procedures were seen to be in place to support the quality assurance process. Regular audits were carried out by the home manager and the area manager. These covered a range of areas such as; The environment Medication Personal plans Maintenance Accidents and Incidents. Stormont Lodge, page 18 of 22

19 We saw that action plans had been developed to address any issues highlighted in the audit process. The service was seen to be very quick to take action in these areas. An example of this was the action taken by the service following a medication error; additional training, supervision and more frequent audits were introduced to minimise the risk of an error reoccurring. Detailed minutes of meetings were examined. These were seen to be very informative and provided a very good insight into the quality assurance processes used by the service. Action plans were generated following each meeting. These provided the service with a clear audit trail of any actions that were required to be taken, by whom and by when. Overall we thought that the services quality assurance processes were robust and provided a very good level of information and detail. Areas for improvement The service should continue to monitor and evaluate the very good level of practice identified in this statement. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Stormont Lodge, page 19 of 22

20 4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information N/A Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). Stormont Lodge, page 20 of 22

21 5 Summary of grades Quality of Care and Support Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Environment Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Staffing Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Management and Leadership Very Good Statement 1 Statement Very Good 5 - Very Good 6 Inspection and grading history Date Type Gradings 24 Jul 2012 Unannounced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 26 Nov 2010 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Stormont Lodge, page 21 of 22

22 To find out more about our inspections and inspection reports Read our leaflet 'How we inspect'. You can download it from our website or ask us to send you a copy by telephoning us on This inspection report is published by the Care Inspectorate. You can get more copies of this report and others by downloading it from our website: or by telephoning Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: enquiries@careinspectorate.com Web: Stormont Lodge, page 22 of 22