Belgrave Lodge Nursing Home Care Home Service Adults 45 Belgrave Road Edinburgh EH12 6NG Telephone:

Transcription

1 Belgrave Lodge Nursing Home Care Home Service Adults 45 Belgrave Road Edinburgh EH12 6NG Telephone: Type of inspection: Unannounced Inspection completed on: 16 January 2015

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 19 5 Summary of grades 20 6 Inspection and grading history 20 Service provided by: Dixon Sangster Partnership Service provider number: SP Care service number: CS If you wish to contact the Care Inspectorate about this inspection report, please call us on or us at enquiries@careinspectorate.com Belgrave Lodge Nursing Home, page 2 of 23

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 4 Good Quality of 4 Good Quality of 4 Good Quality of Management and Leadership 4 Good What the service does well The service provides a homely, caring environment for service users. Staff in the service know the individual likes and dislikes of people in their care and recognise the importance of offering choice. What the service could do better The service needs to further develop staff 1-1 supervision and develop the way in which records of staff training are maintained. What the service has done since the last inspection The service has met most of the recommendations which we made following our previous inspection. This has created improvement in a number of areas including falls management and life history work. Conclusion Belgrave Lodge provides a good level of care within a small, friendly environment. Service users are valued as individuals and staff are caring and attentive. Belgrave Lodge Nursing Home, page 3 of 23

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 needs to do more to improve, we may make a recommendation or a 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 based on best practice or National Care Standards. 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 ("the Act") and secondary legislation under the Act or a condition of registration. Where there are breaches of Regulations, Orders or conditions, a requirement may be made. Requirements are legally enforceable at the discretion of the Care Inspectorate. Belgrave Lodge Nursing Home is owned and managed by Dixon Sangster Partnership. They are referred to as the provider of the service in this report. The home is registered to provide care for up to 33 older people. It is in a quiet residential area but shops and other community services are nearby. The home is close to main bus routes to and from the city centre. There are three floors. All of the public rooms are on the ground floor. There are 31 single bedrooms and two twin bedrooms. Bedrooms with en suite facilities are on the first and second floors. These can be reached by stairs or a lift. There is one bedroom on the ground floor. There is an enclosed garden with a patio and seating area. There is also a small car park to the side of the building. The home's aims and objectives include the statements: "To ensure that any care planned is carried out in consultation with our residents and families ensuring that the residents desired outcomes are met. To ensure that for everyone life is for living, achieving and dreaming, we will achieve this by reasonably assessing risk and not becoming risk averse". Belgrave Lodge Nursing Home, page 4 of 23

5 Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade Quality of - Grade Quality of - Grade Quality of Management and Leadership - Grade 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. Belgrave Lodge Nursing Home, page 5 of 23

6 2 How we inspected this service The level of inspection we carried out In this service we carried out a high intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection We wrote this report following an unannounced inspection. The inspection took place on Wednesday 07 January We gave feedback to the manager at the end of the inspection. As part of the inspection we took account of the completed annual return and selfassessment forms which we asked the provider to complete and submit to us. During the inspection process we gathered evidence from various sources, including the following: We spoke with: The Manager. The Provider. Three members of staff. Four people who use the service. We reviewed: Three personal plans of people who use the service. Medication administration records. Service user dependency assessments Minutes of service users' review meetings. Minutes of service users' meetings Staff training records. Audits carried out by the provider on different aspects of the serviced. We looked at: The environment and equipment used in the provision of the service. We used the Short Observational Framework for Inspection (SOFI2) to directly observe the experience and outcomes for people who were unable to tell us their views. On this inspection we used SOFI2 to observe staff interactions with two individuals. Belgrave Lodge Nursing Home, page 6 of 23

7 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 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 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 Belgrave Lodge Nursing Home, page 7 of 23

8 What the service has done to meet any requirements we made at our last inspection The requirement The service provider must ensure that staff receive training about the use of any assessment tools that are used for pain management. This is to comply with the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations SSI/2011/210 Regulation 15(b). What the service did to meet the requirement During the inspection we noted good practice in relation to pain management. Staff appeared familiar with the assessment tool in use. Staff had received recent appropriate training which included pain management. The requirement is: Met - Within Timescales 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 provider. Taking the views of people using the care service into account People using the service made a number of positive comments about Belgrave Lodge. These included: "They ask me what I think" and "I like it here, the staff are kind. Belgrave Lodge Nursing Home, page 8 of 23

9 Taking carers' views into account We did not meet any carers during our inspection. Belgrave Lodge Nursing Home, page 9 of 23

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: 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 was demonstrating good practice in areas covered by this Quality Statement. We saw that the service continued to use a good range of methods to inform and involve service users and relatives.these included service users' and relatives' meetings, a newsletter and suggestion and complaints processes. We found that the manager was readily accessible to service users and relatives.in addition,the provider frequently visited the home and had regularly attended relatives' meetings.we concluded that this greatly assisted communication between all parties. Six monthly reviews of care were held and involved family members wherever possible. Life histories were now being compiled with the assistance of service users and relatives.the information gained could be used to plan activities which were meaningful to individual service users. There was a range of information available throughout the home on menus. We spoke to service users who confirmed that they felt well informed about meal choices. We looked at the minutes of service users' meetings. We could see from the record of the previous meeting that the subject of activities had been discussed with a suggestion being made by service users to introduce games of Bingo. During our inspection we found that this suggestion had been adopted. We saw a group of service users enjoying a game. Belgrave Lodge Nursing Home, page 10 of 23

11 We concluded that service users' suggestions were acted upon. Areas for improvement The previous service users' meeting had been held in September 2014.The service should consider whether or not the current frequency of meetings best meets the needs/wishes of service users and their family members. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths We found that the service was demonstrating good practice in areas covered by this Quality Statement. We found that all service users looked well. We reviewed a number of personal plans and found these to be well ordered, easy to follow and regularly updated. A range of health assessments were used to support a consistent level of care.. These included M.U.S.T. (Malnutrition Universal Screening Tool), Pressure Ulcer Risk Assessment and Falls risk assessment, We could see that a range of healthcare professionals were involved in the care of service users where more specialist input was required. We reviewed medication administration and concluded that this was well managed. Two recommendations we made following our previous inspection had been met.this had resulted in improved practice in relation to managing falls and greater consistency in pressure ulcer prevention. We observed lunch being served. We noted that staff appeared very familiar with service users' needs. Choice was consistently offered to service users. All service users appeared to receive an appropriate level of assistance in a relaxed setting. Service users with whom we spoke made positive comments about the care they received and the qualities of staff. Belgrave Lodge Nursing Home, page 11 of 23

12 Areas for improvement The completion of individual life histories had provided a range of additional information which might be used to enhance the care of individual service users.an example of this was a service user who described enjoying a long soak in the bath and another person who described an interest in gardening. The service should ensure that information gained in this way is used to plan and inform service users' future care. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Belgrave Lodge Nursing Home, page 12 of 23

13 Quality Theme 2: Quality of Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths As noted in Quality Statement 1.1 we found that the service was demonstrating good practice in relation to areas covered by this Quality Statement. Areas for improvement As noted in Quality Statement 1.1 with regards assessing and improving the quality of the environment within the service. Grade awarded for this statement: 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 was demonstrating good practice in areas covered by this Quality Statement. We found that the overall environment was clean with no obvious sources of danger. We assessed that there appeared to be sufficient staff present to meet service users' needs. There was a system of accident/incident analysis.this was used to identify the cause of any adverse events with a view to preventing re-currance. The service maintained records of safety checks carried out on equipment used in the home. The service had a programme of risk-assessment which identified things which could be harmful and considered ways to lessen the risk. Belgrave Lodge Nursing Home, page 13 of 23

14 Wet-floor showers had recently installed wet-floor showers. This gave service users a choice of bath or shower and lessened the risk to people who had difficulty accessing a bath. Areas for improvement The service planned to upgrade the sluice areas (rooms where hygienic waste is disposed of). This had been identified as an area for development during our previous inspection and was very much in the provider's plans for improvement. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Belgrave Lodge Nursing Home, page 14 of 23

15 Quality Theme 3: Quality of Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths As noted in Quality Statements 1.1 and 2.1 we found that the service was demonstrating good practice in areas covered by this Quality Statement. Areas for improvement As noted in Quality Statements 1.1 and 2.1 with regards assessing and improving the quality of staffing in the service. Grade awarded for this statement: 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 was demonstrating good practice in areas covered by this Quality Statement. We found that staff were enthusiastic and caring. Staff told us that they felt supported in their role. There was a staff training programme appropriate to the needs of the service. Staff supervision was being developed within the service. Supervision records showed us that discussion took place around issues which were important in the development of staff such as training and teamworking. Service users spoke highly of the support they received from staff. Belgrave Lodge Nursing Home, page 15 of 23

16 Areas for improvement Meetings for registered nurses tended to happen only when there was a piece of information to share. We wondered whether these meetings might be used to discuss practice issues and develop and maintain knowledge. The service should explore whether or not there is value in this idea. The service should continue to develop staff 1-1 supervision. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Belgrave Lodge Nursing Home, page 16 of 23

17 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 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 As noted in Quality Statements 1.1,2.1 and 3.1 we found that the service was demonstrating good practice in areas covered by this Quality Statement. Areas for improvement As noted in Quality Statements 1.1, 2.1 and 3.1with regards assessing and improving the quality of management and leadership of the service. Grade awarded for this statement: 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 was demonstrating good practice in areas covered by this Quality Statement. Some effective systems were in place to check on the quality different aspects of the service. Audits were carried out on areas such as medication administration, care plans and accidents and incidents. During the previous inspection we made two recommendations under this Quality Statement. During this inspection we found that both recommendations had been met. This resulted in improved practice in relation to the management of service users' finances and the updating of care policies and procedures. Areas for improvement We found that there was no overview of the training needs of the staff group as a whole.(training Matrix) Belgrave Lodge Nursing Home, page 17 of 23

18 This is a very valuable tool in the identification of training needs. We have made a recommendation about this.(see recommendation 1). Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service should maintain an accurate and accessible overview of the training needs of staff. In order to do this the service should develop a staff training matrix which gives "at a glance" information on training completed by all staff. National Care Standards, Care Homes for Older People. Standard 5: Management and Arrangements. Belgrave Lodge Nursing Home, page 18 of 23

19 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 No Additional Information. 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 Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). Belgrave Lodge Nursing Home, page 19 of 23

20 5 Summary of grades Quality of Care and Support - Statement 1 Statement 3 Quality of - Statement 1 Statement 2 Quality of - Statement 1 Statement 3 Quality of Management and Leadership - Statement 1 Statement 4 6 Inspection and grading history Date Type Gradings 3 Mar 2014 Unannounced Care and support 3 - Adequate Management and Leadership 3 - Adequate 3 Mar 2014 Unannounced Care and support 3 - Adequate Management and Leadership 3 - Adequate 6 Aug 2013 Unannounced Care and support 2 - Weak 3 - Adequate Management and Leadership 3 - Adequate Belgrave Lodge Nursing Home, page 20 of 23

21 14 Jun 2013 Re-grade Care and support 2 - Weak Management and Leadership 20 Dec 2012 Unannounced Care and support 3 - Adequate Management and Leadership 3 - Adequate 13 Aug 2012 Unannounced Care and support 3 - Adequate Management and Leadership 3 - Adequate 9 Feb 2012 Unannounced Care and support 3 - Adequate Management and Leadership 30 Sep 2011 Unannounced Care and support 2 - Weak 3 - Adequate 3 - Adequate Management and Leadership 3 - Adequate 10 Aug 2011 Re-grade Care and support 2 - Weak Management and Leadership 10 May 2011 Unannounced Care and support 3 - Adequate 3 - Adequate 3 - Adequate Management and Leadership 3 - Adequate 22 Feb 2011 Announced (Short Notice) Care and support Management and Leadership 2 - Weak Belgrave Lodge Nursing Home, page 21 of 23

22 16 Dec 2010 Unannounced Care and support 2 - Weak 3 - Adequate 3 - Adequate Management and Leadership 2 - Weak 28 Sep 2010 Announced Care and support 2 - Weak 2 - Weak 2 - Weak Management and Leadership 2 - Weak 23 Mar 2010 Unannounced Care and support 3 - Adequate 3 - Adequate 3 - Adequate Management and Leadership 3 - Adequate 3 Nov 2009 Announced Care and support 2 - Weak 2 - Weak 2 - Weak Management and Leadership 3 - Adequate 9 Jan 2009 Unannounced Care and support 3 - Adequate Management and Leadership 8 Aug 2008 Announced Care and support 3 - Adequate Management and Leadership All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Belgrave Lodge Nursing Home, page 22 of 23

23 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: Belgrave Lodge Nursing Home, page 23 of 23