Carrondale Nursing Home Care Home Service Adults Beaumont Drive Carron Falkirk FK2 8SN Telephone:

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1 Carrondale Nursing Home Care Home Service Adults Beaumont Drive Carron Falkirk FK2 8SN Telephone: Inspected by: Lesley Greig Type of inspection: Unannounced Inspection completed on: 17 January 2012

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 6 3 The inspection 11 4 Other information 19 5 Summary of grades 20 6 Inspection and grading history 20 Service provided by: Avondale Care (Scotland) Limited Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Lesley Greig Telephone enquiries@scswis.com Carrondale Nursing Home, 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 Quality of Staffing N/A N/A Quality of Management and Leadership 5 Very Good What the service does well The work of the activity staff is recognised as being a significant strength of the service. Residents continue to be offered a range of activities, both in house and outwith the care home, in a manner that is in keeping with their needs, wishes and preferences. We saw that the care home environment was well maintained, clean and warm which was appreciated by the people in residence. Residents and their relatives gave us very positive feedback on the quality of the staff and management. We saw some very good care practice during the inspection which resulted in peoples care and support needs being met in a sensitive and respectful manner. What the service could do better We found that care planning and the management of regular reviews of care could be improved. This would help the service to better demonstrate the good work which is being carried out. Audit systems could also be improved to help the service to monitor and evaluate areas such as care planning and care practice to promote person centred approaches. Carrondale Nursing Home, page 3 of 22

4 What the service has done since the last inspection Since the last inspection work has continued to offer residents and their relatives opportunities to have their say on the quality of the service. We saw that there were a range of ways that people could take part and get involved in service development. Conclusion Overall we found that the service was operating to a very good level. In or Who did this inspection Lesley Greig Carrondale Nursing Home, page 4 of 22

5 1 About the service we inspected Carrondale Home was registered by the Care Commission on 1 April It provides a care service to a maximum of 72, older people in four separate units. The Units are: Jura, a maximum of 26 older people; Skye, a maximum of 25 older people; Arran, a maximum of 11 older people with dementia; and Islay, a maximum of 10 older people with dementia. This number generally always includes one person having a short stay. Many of the people in the care home have dementia and other physical and/or mental health support needs associated with aging. Carrondale Home is located within the residential area of Carron in Falkirk and is close to a range of local amenities. The building is purpose built over two floors with single room accommodation and en-suite facilities. There are extensive gardens to the rear of the property which is on the bank of the River Carron. There is ample parking to the front of the property. The aims and objectives of the care home are linked to a statement of values and include the aim to deliver a service of the highest quality that will improve and sustain resident's overall quality of life. 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 - N/A Quality of Staffing - N/A Quality of Management and Leadership - Grade 5 - Very Good 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. Carrondale Nursing Home, 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 We wrote this report after an unannounced inspection which took place over three days, 14 December 2011 and 11 and 17 January The inspection was carried out by inspector Lesley Greig. As requested by us, the provider sent us an annual return. The provider also sent us a self assessment form. We issued 30 questionnaires to residents and 30 questionnaires to relatives/carers before the inspection. Fifteen residents and 22 relative/carers completed and returned questionnaires to us which we used to inform our assessment of the quality of the service. In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents and activities, including: evidence from the service most recent self assessment the service participation policy accident and incident records a sample of residents personal plans records of activities the service newsletter care plan audits minutes of meetings, including residents and relatives meetings and health and committee meetings questionnaires and surveys carried out by the service action plans put in place following meetings, questionnaires and surveys During the inspection we had discussions with: residents visiting relatives Carrondale Nursing Home, page 6 of 22

7 the manager the deputy manager care staff activity staff We spent time in communal areas of the home paying attention to how staff worked with and cared for residents and we made observations of the environment (for example was it clean, was it set out well, was it easy to access by people using wheelchairs, were people able to use garden areas and access fresh air?). 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 Carrondale Nursing Home, page 7 of 22

8 What the service has done to meet any recommendations we made at our last inspection We made no recommendations in the last report. 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. We received a fully completed self assessment document from the service provider when this was requested. We were satisfied with the way the service provider had completed this and with the relevant information they had given us for each of the 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. We would encourage the service to consider how some of the strengths identified in the self assessment result in positive outcomes for residents and their relatives/ carers and provide this outcome focused information in their next self assessment. Taking the views of people using the care service into account We issued 30 questionnaires to the people who live in Carrondale and 15 were completed and returned to us before the inspection. Overall, everyone who responded either agreed or strongly agreed that they were happy with the quality of the service. Comments from some residents included: 'I go out for a bar lunch and have a pint, it's good to get out and about.' 'I'm very comfortable thank you, I enjoy quizzes and crossword puzzles, they help to keep my mind active.' 'Sometimes it can be lonely, I don't like to bother the staff too much.' 'Overall the care is excellent, the staff are very caring and friendly.' Carrondale Nursing Home, page 8 of 22

9 'Some personal property goes missing... some personal property is used by others.' Taking carers' views into account We issued 30 questionnaires to relatives/carers of the people who live in Carrondale and 22 were completed and returned to us before the inspection. Overall, everyone who responded either agreed or strongly agreed that they were happy with the quality of the service. We spoke with 4 visiting relatives during the inspection. Relatives confirmed that they were very happy with the care and support that the service delivered and spoke highly of the staff team. One relative commented that he would give the service '10 out of 10' and described it as 'excellent.' Relatives comments gathered through the returned questionnaires and during the inspection included: 'I stay and have a meal with my relative from time to time, the food's very nice and the staff all go out of their way to make me feel welcome. I'm so relieved to know that she's well looked after.' 'It's a very good care home. My mother is settled and the staff know how to care for her. If I was worried or unhappy about anything I would speak to the staff but everthing's fine.' 'The staff are brilliant, they always include my mum in as much activity as possible.' 'They (the staff) look after my relative as an individual, not simply a resident.' 'Overall we are very happy with the cleanliness and meals and it always looks tidy.' 'I am very happy with all the staff who care for my relative and feel that she is very well looked after. The staff always keep me informed.' 'There is a very high staff turnover which is worrying and upsetting for the residents.' 'My relative has suffered a number of falls which seem to happen during night shift. Are there enough staff on duty during the night?' 'The state of the carpet in the bedroom leaves a lot to be desired...they are a bit smelly...the number of residents who share one shower is not very healthy or hygenic.' 'I sometimes feel my relative is no longer an individual with their own special needs, and not all staff are aware of the personal care plan. Not enough stimulation, on many visits residents are just sitting, not even facing the TV, not conversing (where possible) with staff who are looking just as bored.' Carrondale Nursing Home, page 9 of 22

10 'With some members of staff, requests to sort out a problem are taken as a personal attack on their competence when it's simply an attempt to make sure my relative is as comfortable, healthy and happy as possible.' We would encourage the service to explore some of the concerns identified. Carrondale Nursing Home, page 10 of 22

11 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 Overall 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 The service was achieving very good standards in the areas covered by this statement. We found that there were a range of ways in which residents and their relatives/carers could get involved and have their say on the quality of care and support in the service. These included: Questionnaires and surveys. The service issued a comprehensive questionnaire to residents each year which asked people about the quality or care and support. In addition to an annual questionnaire the service also carried out focused surveys. For example, we saw a lot of work had been done to look at the menu and mealtime preferences. The information gathered had been collated and action plans had been developed which showed that the service took action to make changes as a result of residents and their relatives/carers views and preferences. A monthly news letter which was considered to be informative and wide ranging. The newsletters included information and stories about activities, entertainment and outings, staffing and encouraged people to get involved and share their views. A key worker/named nurse system which could be helpful in supporting continuity of care, information sharing and communication. Frequent and planned social events which provided residents and their relatives/carers with regular informal opportunities to share their views and make suggestions. There had recently been a cheese and wine event which had been well attended. We saw the service clearly displayed information on advocacy services and the complaints procedure on notice boards around the home. Activity information, the Carrondale Nursing Home, page 11 of 22

12 newsletter and other useful information was also on display helping to keep people informed. We spent time in communal areas of the home speaking with residents and watching how staff worked and saw some very good care practice. This included staff explaining what they were doing and how they were going to help people who needed support with their mobility, offering support with personal care in a discrete and sensitive manner and staff encouraging people to make choices and take part in discussions. We spoke with the activity staff and looked at their record keeping systems. We were very impressed with way the activity staff worked with residents and their relatives/ carers to offer meaningful and individualised activity both within and out with the home. Activity staff were able to demonstrate how they made sure that all residents were offered regular opportunities for outings. Residents we spoke with confirmed that they enjoyed things like bar lunches, shopping trips, day trips, theatre visits and tea dances on a regular basis. Records showed that the activity staff were regularly monitoring and evaluating their work to make sure the activities provided were in line with residents needs, wishes and preferences. We examined the completed questionnaires which were returned to us. Everyone who responded either agreed or strongly agreed that overall they were happy with the quality of care and support provided by the service. Areas for improvement On a occasion we saw that residents were not provided with the support they needed in a timely manner despite their care needs being clearly detailed in their plan of care. As an area for improvement the management should ensure that all staff are familiar with residents care needs and act to respond to these in a timely manner. We examined a sample of residents personal plans. While we saw some very good and detailed records which clearly showed what residents support needs were and how they should be met, we also saw that some care planning was generic and did not reflect residents actual needs. We discussed care planning and record keeping with the manager and deputy manager. We have suggested, as an area for improvement, that where residents have more complex healthcare needs their care planning should be nurse led, or at least have a nursing overview, to ensure appropriate interventions are identified and documented. It was not always clear how all residents and/or their relatives/carers had been involved in agreeing plans of care or risk management measures. The service should consider how this could be better demonstrated. Carrondale Nursing Home, page 12 of 22

13 We would strongly encourage the service management to consider reviewing the personal planning record keeping systems in place. We found a lot of time was being spent duplicating information that was already recorded, and it was unclear why some care planning was being carried out across several plans of care. Through reducing the quantity of record keeping the care service may find it easier to focus on the quality of care planning. The management should consider how this area could be developed to ensure care planning is improved. The service identified through their self assessment that residents and enquirers to the service had frequently mentioned the use of SKYPE to contact relatives overseas. They identified that this will be implemented in the small quiet room in Jura unit. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Carrondale Nursing Home, page 13 of 22

14 Quality Theme 2: Quality of Environment - NOT ASSESSED Carrondale Nursing Home, page 14 of 22

15 Quality Theme 3: Quality of Staffing - NOT ASSESSED Carrondale Nursing Home, page 15 of 22

16 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 refer to Quality Theme 1 statement 1, areas of strength, for methods of participation which were also relevant to this statement. We found that the service was achieving very good standards in relation to this statement. As previously discussed the service had a range of methods in place to ensure that residents and their relatives/carers had opportunities to share their views on the management and leadership of the service. These included: formal and informal meeting forums and social events, questionnaires and surveys, a regular service newsletter and a named key worker/named nurse system. One example of involvement which had resulted in positive change and improvement was relatives involvement in the service health and safety committee which resulted in the purchase of emergency moving and handling equipment. The service had a complaints procedure which was displayed around the home. Relatives we spoke with knew about this and confirmed they would be comfortable approaching the manager if they had any concerns. Areas for improvement While we acknowledge that some residents personal plans had been signed by their relatives/carers, we found little information to demonstrate that all residents and their relatives/carers were given the opportunity to take part in a full review of care on at least a six monthly basis. As an area for improvement, formal and documented reviews of care, involving residents, relatives/carers and any other interested parties, should be developed. This would be an additional means of the service gathering feedback on the quality of management and leadership. Carrondale Nursing Home, page 16 of 22

17 The service is achieving very good outcomes in this area and should continue to pro actively seek out opportunities for people to become meaningfully involved in the assessment and improvement of the service. 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 care service was achieving a very good standard in relation to the areas covered by this statement. The management carried out a range of regular audits which could help them to monitor the quality of the service. These included audits of care plans, medication, accidents and incidents, housekeeping, meal times, residents dining experience and the laundry service. We saw that the service develops action plans following audits to make any changes or improvements identified. Annual questionnaires and additional surveys are carried out, involving residents and their relatives/carers, which gives people regular opportunities to comment and make suggestions for improvement. These systems also help the management to monitor levels of satisfaction with the service being delivered. Relatives and residents spoken with confirmed that the staff and management of the service are accessible to them. During the inspection we saw that the management were highly visible around the service. The manager has set up a regular surgery which offers people the opportunity to meet with her formally. Surgery times were displayed around the service which could help to keep people informed of this additional means of having a say. Areas for improvement From examination of a sample of care plans we found that the audits which had been carried out had not always identified areas of care planning which should be improved. We discussed this with the management who agreed there was some room for improvement which they will act upon. We would also suggest that a system is put in place to record which care plans had been audited to make sure none were being missed. We will follow this up at the next inspection. Carrondale Nursing Home, page 17 of 22

18 We reviewed a sample of personal plans and discussed care assessments and plans with the management. We saw that most personal plans were evaluated and updated on a monthly basis. It was unclear that formal care review meetings, which are attended by the people who use the service and their relatives or representatives, had been taking place at least every six months. We have asked the service management to look at formal systems of review to make sure that all residents and their relatives/ carers have regular formal opportunities to take part in a full review of care. We will follow this up at the next inspection. The care service should continue to monitor and maintain the high standards of quality. They should ensure they are rigorous in identifying any areas for improvement and implementing action plans to address these. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Carrondale Nursing Home, page 18 of 22

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 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 SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). Carrondale Nursing Home, page 19 of 22

20 5 Summary of grades Quality of Care and Support Very Good Statement Very Good Quality of Environment - Not Assessed Quality of Staffing - Not Assessed Quality of Management and Leadership Very Good Statement 1 Statement Very Good 5 - Very Good 6 Inspection and grading history Date Type Gradings 13 Jul 2010 Announced Care and support 6 - Excellent Environment Not Assessed Staffing 6 - Excellent Management and Leadership Not Assessed 13 May 2010 Announced Care and support 5 - Very Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed 13 Jan 2010 Unannounced Care and support Not Assessed Environment Not Assessed Staffing Not Assessed Management and Leadership 5 - Very Good 25 Aug 2009 Announced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 26 Feb 2009 Re-grade Care and support 4 - Good Carrondale Nursing Home, page 20 of 22

21 Environment Staffing Management and Leadership 4 - Good 4 - Good 4 - Good 3 Feb 2009 Unannounced Care and support Not Assessed Environment Not Assessed Staffing Not Assessed Management and Leadership 4 - Good 18 Jun 2008 Announced Care and support 2 - Weak Environment 2 - Weak Staffing 2 - Weak Management and Leadership 2 - Weak All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Carrondale Nursing Home, 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 SCSWIS. 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@scswis.com Web: Carrondale Nursing Home, page 22 of 22