Belhaven House Care Home Service Adults 3 Craigend Road Troon KA10 6ER

Transcription

1 Belhaven House Care Home Service Adults 3 Craigend Road Troon KA10 6ER Type of inspection: Unannounced Inspection completed on: 21 August 2014

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 11 4 Other information 42 5 Summary of grades 43 6 Inspection and grading history 43 Service provided by: Mansfield Care Limited 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 Belhaven House, page 2 of 45

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 1 Unsatisfactory Quality of Environment 1 Unsatisfactory Quality of Staffing 1 Unsatisfactory Quality of Management and Leadership 1 Unsatisfactory What the service does well Service users spoke highly of individual staff and acknowledged that, despite being very busy, staff presented as being caring and considerate. The provider and management team demonstrated a willingness to improve the service and address any issues highlighted. What the service could do better Following this inspection the Care Inspectorate has highlighted the following areas for improvement: The Provider needs to ensure that there are sufficient numbers of staff on every shift to deliver essential care and meet resident's needs. The Provider must ensure that he meets the conditions of the staffing schedule. The service needs to ensure that it meets the essential health and wellbeing needs of service users. The service needs to expand and develop keyworker responsibilities to ensure that the delivery of care planning is in a more person centred way. The Provider should ensure that the service is delivered in a way that promotes quality and safety and respects the independence of residents, and affords them choice in the way in which the service is provided to them. Infection Control practices need to be improved, particularly in the downstairs bathroom. Belhaven House, page 3 of 45

4 The service should offer residents a range of appropriate, purposeful, recreational and stimulating activities on a regular basis. The provider should ensure that care plans are up to date and followed on a daily basis. They should include details of people's changing health needs and demonstrate how these are being addressed, to ensure care needs are not overlooked. Residents should be consulted about menu planning. In addition, meal times should be a positive experience where service users are supported to enjoy their meals and they should be served timeously. The management team should lead by example and promote a positive culture which demonstrates the values and principles of the National Care Standards. Quality assurance processes need to be improved to include views from service users and their representatives, staff and other professionals. What the service has done since the last inspection The service has not sustained progress since the last inspection in on 8 November Conclusion The service grades have decreased since the last inspection on 8 November The service has not sustained the good practice demonstrated at the last inspection and we are concerned that positive outcomes for service users are compromised. This service has recently undergone some changes in the external management of the home. Although some resident response to the service provided by Belhaven was positive, we feel that the service has dramatically deteriorated. Belhaven House, page 4 of 45

5 1 About the service we inspected Before 1 April 2011 this service was registered with the Care Commission. On this date the new scrutiny body, Social Care and Social Work Improvement Scotland (SCSWIS), took over the work of the Care Commission, including the registration of care services. This means that from 1 April 2011 this service continued its registration under the new body, SCISWIS. We are also known as the Care Inspectorate. 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 and 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 Inspectorate. Belhaven House is situated near the shore front in the town of Troon on the Ayrshire coast. The service was registered with the Care Inspectorate on the 1 December Belhaven House is registered to provide care and support to a maximum of 34 older people where some of these places can be used for short stay/respite care. At the time of this inspection, the service had 27 people living in it of which none were receiving respite care. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 1 - Unsatisfactory Quality of Environment - Grade 1 - Unsatisfactory Quality of Staffing - Grade 1 - Unsatisfactory Quality of Management and Leadership - Grade 1 - Unsatisfactory This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Belhaven House, page 5 of 45

6 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. Belhaven House, page 6 of 45

7 2 How we inspected this service The level of inspection we carried out In this service we carried out a medium 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 In this service we carried out a medium intensity inspection. We wrote this report after the unannounced inspection that took place on: 31 July between 12:30 and 21:00 01 August between 09:00 and 16:00 06 August between 17:30 and 21:00 The feedback was given to the services Project Manager and Manager on 21 August Two Inspectors carried out the inspection. They were accompanied by a Complaints Inspector for part of the inspection. During the inspection process, we gathered evidence from a number of sources including some of the following records: Register of service users Care files (6) Care reviews (6) Staff communication records Complaints records Staff rotas Communication records Accident /incident records Certificate of Registration Staffing Schedule Insurance details Participation Strategy Medication records Self assessment We spoke with the following people: Service users (9) Relatives (6) Manager Project manager Belhaven House, page 7 of 45

8 Operational manager Nurses (2) Care Staff (5) Activity Co-ordinator Handyman We sent out 20 questionnaires and received 0 from people who use the service. We sent out 20 questionnaires to relatives and carers and received 3; and, we sent out 20 staff questionnaires and received 6. We also spent time with residents, meeting them in groups and individually and observed practice. 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 Belhaven House, page 8 of 45

9 What the service has done to meet any requirements we made at our last inspection The requirement The Provider must ensure that medication procedures are accountable and all changes are recorded, authorised and audited. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. Timescale for implementation: within 3 months of receipt of this report. What the service did to meet the requirement We looked at medication procedures and Medication Administration Records (MAR). We found that where there were handwritten amendments, these were now authorised and accountable. The requirement is: Met - Within Timescales What the service has done to meet any recommendations we made at our last inspection The service has not made sufficient progress on reccomendations made in the previous 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 Belhaven House, page 9 of 45

10 Comments on Self Assessment Inspection report continued 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. The service provider identified what they thought they did well, and some areas for development. Taking the views of people using the care service into account We met with service users and also took account of returned questionnaires. They said: "I'm quite happy" "Very seldom see a menu-today is the first time" "Staff look after us well but not enough of them" "Could do with more staff between meal times" Taking carers' views into account We refer to relatives, friends and advocates as carers. They do not include care staff: "We are always made to feel welcome" "Staff do a great job but could do with more especially in the afternoon" "I think it is a good home" "Overall the care home is fine. Staff excellent. Any concerns we have are usually minor and dealt with." "I am completely happy with the treatment my XX gets at Belhaven." Belhaven House, page 10 of 45

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 Grade awarded for this theme: 1 - Unsatisfactory 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 grade awarded for this Quality Statement at the last inspection on 8 November 2013 was 4 - very good. The evidence we sampled at this inspection has lowered this grade to 2 - Weak. We concluded this after we spoke with residents, staff and the manager. We also took account of personal plans, minutes of meetings and other supporting information. Two recommendations made at the last inspection were not met as follows: 1. The service should implement their Quality Assurance systems and Participation Strategy. They should increase and demonstrate the extent to which it takes into account the views of service users, relatives and staff in improving the service. The service should clearly identify matters arising and action taken. National Care Standards for Care homes for older people: Standard 11 - Expressing your views - Action taken. The service was not able to demonstrate how they took people's views into account. The services own Quality Assurance systems and Participation Strategy had not been implemented. We noted limited meaningful engagement for some people and have now made this recommendation a requirement. (See areas for development for further information). 2. The keyworker system should continue to be developed to ensure that residents Belhaven House, page 11 of 45

12 care plans are fully implemented and that staff have the time to discharge their responsibilities. This should include activities which are not always task orientated. National Care Standards Care Homes for Older People, Standard 6, Support Arrangements. We found that staff did not have time to discharge their keyworker duties. This recommendation is repeated. (See areas for development for further information). The service engaged in a variety of ways. This included: * Face to face discussions with individual service users * Reviews There was evidence that service users and their carers were involved in the care planning process. Reviews were held with participation from carers where the service user had indicated they wished their relative to be involved. On review of a sample of service users' care plans, we found evidence of where personal choices sought from the service users themselves and their families. These were reviewed six monthly. There was a range of information displayed in the hallway and noticeboards within the home including the most recent inspection report, participation strategy, newsletters, complaints procedure and relatives meeting minutes. The service has a brochure. This includes a section on "resident and relatives involvement" stating how the service intends to seek views from people using the service. For example, the service has an "open door policy" and "encourages visits from friends and relatives". A complaints procedure was in place. Areas for improvement The service had not sustained the methods of engagement apparent at the last inspection in November The service should implement its Quality Assurance processes and participation strategy and show how feedback from service users and carers has led to improvements in the service. Any feedback should be evaluated, and reflect improvements made. This should include auditing of complaint activity to improve the service. This information should be made available to service users. The service should introduce relatives and residents meetings and enable people to engage in a meaningful and inclusive manner at different levels. (See Requirement 1 of this Quality Statement) Inspection report continued Belhaven House, page 12 of 45

13 The home operates a keyworker system. However, on the day of inspection, interaction between staff and service users was limited. Any engagement we observed was task orientated and both residents and staff told us that there were not enough people to carry out keyworker tasks. The previous recommendation is repeated. (See Recommendation 1 of this Quality Statement ) On the days of inspection, the atmosphere in this service was tense and strained. We found that residents did not enjoy a light and relaxed ambience. Residents confirmed that staff did not have much time for them but were grateful for the care they received. The service should involve relatives, residents and stakeholders in assessing and improving the quality of the care and support they receive. Other methods of engagement should also be identified and implemented. The last inspection noted that a new activity coordinator has recently started. On the days of inspection, we observed no individual or group activities taking place. Staff did not spend one to one time with service users. During inspection, we saw that there were few staff around to interact with the residents as they were busy attending to peoples immediate needs such as assisting with toileting and assisting with serving and supporting residents with eating. We saw that the more able residents were left unattended for large periods of time. For example: There are 2 dining rooms. All the staff were assisting people who needed support to eat in one dining room. As a result, at least 8 residents were left unattended in the other dining room and, despite all sitting at dining tables patiently waiting, they were not served their meal for nearly an hour and we agree with residents that this is unacceptable. (See 1.3 for further information) There are two lounges. At times, there were not enough staff on duty to monitor both lounges as staff were called away to attend to someone else. Service users were left unattended for large periods of time. (See Quality Statement 1.2 and 1.3 for further information). Although the service has a complaints procedure, and people are invited to speak with the senior staff at any time to discuss any concerns, the service needs to ensure that they are more responsive, see peoples issues as being real and are seen to be promoting the values of the National Care Standards. Belhaven House, page 13 of 45

14 Grade awarded for this statement: 2 - Weak Number of requirements: 1 Number of recommendations: 1 Requirements 1. The service should implement their Participation Strategy and increase the extent to which it takes into account the views of service users in improving the service. The service should clearly identify matters arising and demonstrate action taken. This is to comply with the Regulation of Care (Requirements as to Care Services) (Scotland) Regulations 2002 SSI 2011/210 Regulation 4(1) (a) Providers shall make proper provision for the health and welfare of service users. National Care Standards for Care homes for older people: Standard 11 - Expressing your views and Standard 5: Management and Staffing Arrangements Timescale: 8 weeks from receipt of this report. Recommendations Inspection report continued 1. The keyworker system should be developed to ensure that residents care plans are fully implemented and that staff have the time to discharge their responsibilities. This should include activities which are not always task orientated. National Care Standards Care Homes for Older People, Standard 6, Support Arrangements. Statement 2 We enable service users to make individual choices and ensure that every service user can be supported to achieve their potential. Service strengths The grade awarded for this Quality Statement is 2- Weak We concluded this after we talked to residents, carers, the manager and staff. We also took into account supporting documentation such as personal plans, the activity programme and minutes of meetings. We found very little evidence to support this strength. We found that staff were clear about their roles and responsibilities in ensuring that support was delivered to ensure positive outcomes for service users. Belhaven House, page 14 of 45

15 The service had a fete to fund raise for the care home. The service has again recruited a new activity co-ordinator. She had implemented a programme of group activities and also spent time engaging with individuals. There was a church service taking place during inspection and a knitting group had recently started. Areas for improvement We found that insufficient staffing levels, resentment and a lack of understanding from some staff about the role of the activity co-ordinator and the keyworker role were restricting people's choices and potential. At our inspection on 08 November 2013 we were assured that dependency levels would continue to be assessed on a regular basis as an indicator of staffing requirements and the home would be staffed accordingly. However, during this inspection we found that whilst dependency assessments were being undertaken, good quality care had not been sustained resulting in poor care experiences for residents. We found that: * The minimum staffing schedule was being complied with, but did not meet the needs of residents. * We observed residents becoming more agitated by lack of staff intervention. * We noted that, for residents needing additional support due to changing health needs, staff were struggling to provide the level of support required. We are concerned that a lack of appropriate staffing did not enable residents to make choices and realise their potential. For example, activities were limited and there were delays in providing support. (See Requirements 1,2 &,3 of this Quality Statement) During our visits we found limited evidence of activities taking place. The television was on all day in the lounge from early in the morning. We found that staffing levels and deployment were impacting on choices and stimulation for people and that access to meaningful engagement was limited. The service has again recruited a new activity co-ordinator specifically to provide and arrange group and individual activities. However, this is the fifth appointment in 2 years and there is a lack of direction and understanding about the responsibilities and demands of this role. The new activity co-ordinator who has recently started has not received relevant training. There was little evidence of positive stimulation or promotion of the physical and mental health and wellbeing of residents. Belhaven House, page 15 of 45

16 (See Requirement 4 for this Quality Statement). Grade awarded for this statement: 2 - Weak Number of requirements: 4 Number of recommendations: 0 Requirements 1. The provider must provide the service in a manner which promotes quality and safety and respects the independence of service users, and affords them choice in the way in which the service is provided to them. This is in order to comply with: SSI 2011/210 Regulation 3 Principles Timescale: Within 4 weeks from the date of issuing this report. 2. Staffing: a) The provider must ensure that adequate staffing levels are maintained at all times and the staffing schedule is complied with. b) The provider must keep a record of the assessment that identifies the minimum staffing levels and deployment of staff on each shift over a four week period. This will take into account aggregated information of the physical, social, psychological and recreational needs and choices in relation to the delivery of care for all individuals, also taking into account the physical layout of the building, staff training and supervision needs. This is in order to comply with: SSI 2011/210 Regulation 15(a) - a requirement for a provider to ensure that at all times suitable qualified and competent persons are working in the care service in such numbers as are appropriate for the health and welfare and safety of service users. Timescale: Within 3 months from the date of issuing this report. 3. The service provider must ensure that activities offered and provided to service users are appropriate to their individual needs. People who use the care service must be offered a range of appropriate, purposeful, recreational and stimulating activities on a regular basis. This is in order to comply with: SSI 2011/210 Regulation 3 Principles - A provider of a care service shall provide a Belhaven House, page 16 of 45

17 service in a manner which promotes quality and safety and respects the independence of service users, and affords them choice in the way in which the service is provided to them. SSI 2011/210 Regulation 4 (1) (a) Welfare of users - A provider must make proper provision for the health, welfare and safety of service users. National Care Standards for older people - Standard healthcare Timescale: 8 weeks from receipt of this report. 4. The provider must ensure that staff providing activities either solely or as part of their post are appropriately supported, skilled and trained. SSI 2011/210 Regulation 15 (b) (i) Staffing - a requirement to ensure that persons employed in the provision of the care service receive training appropriate to the work that they are to perform. Timescale: Within 6 months of receipt of this report. Inspection report continued Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths The grade awarded for this Quality Statement at the last inspection on 8 November 2013 was 3 - Adequate. The evidence we sampled at this inspection has lowered this grade to 1 - Unsatisfactory. We concluded this after we spoke with residents, staff and the manager. We also took account of personal plans and complaint activity. We made 2 Requirements at the last inspection and found that the provider had met one but not the other as follows: 1. The Provider must ensure that medication procedures are accountable and all changes are recorded, authorised and audited. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. ACTION TAKEN Belhaven House, page 17 of 45

18 We looked at medication procedures and Medication Administration Records (MAR). We found that where there were handwritten amendments, these were now authorised and accountable. (Also see areas for development for further information.) MET 2. The Provider must ensure that all staff are fully aware of all service users' status under the Adults with Incapacity (AWI) Act. In addition, the service must review individual service user's capacity to make informed decisions, and, where necessary, introduce appropriate Certificates of Incapacity. This is in order to comply with: SSI 2010/210 Regulation 4(1)(a): a requirement to make proper provision for health, welfare, and safety of service users. This is to comply with SS1 2011/210, Regulation 4. (1)(a) - a requirement to make proper provision for the health and welfare of service users and Regulation 5. (1) (c) - Personal Plans This should also take account of: National Care Standards, Care homes of older people, Standard 6: Support arrangements. ACTION TAKEN We remain concerned about the lack of awareness by staff of service users' status under the Adults with Incapacity (AWI) Act. We have repeated this requirement. See areas for development for further information. NOT MET Support plans indicated and service users confirmed that they were supported to access primary and other health services. The level of support was flexible depending on the health needs of the service users at any given time. Changes to support in this area were the subject of multi-disciplinary discussion. Staff and service users confirmed that they liaised with community health professionals and others such as social work services and families. Health information was available for staff and service users informing them about various illnesses and about how they could access support. Staff had undertaken training in matters relevant to the promotion of health and well-being of service users. This included: Belhaven House, page 18 of 45

19 * Moving and assisting * Protection of Vulnerable Adults * Dementia * Administration of medicines All residents had a care plan which showed that service users accessed a range of healthcare professionals as required. Areas for improvement The service worked with people who lacked capacity to make informed choices. The service had records for some service users who had formal interventions in place under the Adults with Incapacity (Scotland) Act 2000 (AWI). There were records to confirm who usually dealt with all financial matters and who had responsibility for decisions, in relation to welfare and health needs of service users. However, we remain concerned that the service was not familiar with their responsibilities in relation to AWI nor of people's rights to choice and how decisions were made about care delivery taking account of issues such as risk, safety and rights of people. The management of the service had "reviewed" the services policy regarding the use of lap straps without fully assessing and discussing the implications of these interventions in a transparent manner. We have advised that the staff follow the Mental Welfare Commission Guidance of "Safe to Wander" and "Rights Risks and Limits to Freedom" available at The service has still to source and deliver training for all staff regarding AWI and we have repeated the previous recommendation to monitor progress. (See Requirement 1 of this Quality Statement) The service was using an assessment tool to evaluate the dependency needs and levels of interventions required by individuals. However, this did not take account of people's social needs nor of the physical layout of the building. We noted that because the resident group has decreased to 27, the service management has also reduced care staff without taking account of changing needs. We are concerned that the services own assessments did not identify the increasing care needs of residents and review staffing accordingly. We consider that staffing levels and deployment of staff on all shifts required to be reviewed. Since the provider has failed to take appropriate action, the issue of staffing levels is reflected in the grading for this Quality Statement. In addition, the provider must maintain accurate records which demonstrate that: a) For everyone using the service, a provider shall keep records of four weekly assessments of physical, social, psychological and recreational needs and choices and Belhaven House, page 19 of 45

20 how they will deliver their care. b) In respect of the delivery of the service, a provider should keep a record of assessment that identifies the minimum staffing levels and deployment of staff on each shift over a four-week period. This will take account of aggregated information of the physical, social, psychological and recreational needs and choices in relation to the delivery of care for all individuals, also taking account of the physical layout of the building, staff training and staff supervision. c) The overall assessment of staffing level and deployment must be available to any visitors to the service and everyone using it. (See Requirement 2 of this Quality Statement) The following previous recommendation was not met and we have now made a requirement: The service should continue with the life story work and link it to care planning for all service users. Alongside this, the service should evaluate the role of key workers to ensure their contribution and responsibilities as key workers so that care is delivered in a person-centred manner. ACTION TAKEN Staff understanding of their roles as key workers is still not well established and deteriorated. Any work previously noted in relation to the development of the keyworker role and life story work has stopped. Staff roles are task orientated and care staff spend very little time with their allocated residents. Care staff also reported back to the named nurses who then made entries in service users records. There remains a fragmented approach to care planning rather than care being delivered in a person centred and holistic manner and we have seen little progress. Care staff we spoke with presented as being dedicated and caring. However, they told us they did not always have time to carry out keyworker duties. At this inspection, we found that the service was not fully meeting the essential care needs of residents in the following areas: * Working with people with dementia * Food and fluid management. * Meaningful activity * Social and Psychological wellbeing of residents * Moving and assisting support * Communication with residents and relatives. * Continence Management * Mobility and falls management * Mobility Inspection report continued Belhaven House, page 20 of 45

21 * Tissue Viability * Palliative Care The service should link the above to life story work. Alongside this, the service should evaluate the role of key workers to ensure their contribution and responsibilities as key workers so that care is delivered in a person-centred manner and keyworkers have time to discharge their duties. (See Requirement 3 of this Quality Statement). The service was in the process of updating its care management systems. We sampled both the current system in place and the documentation for the new system. The previous report noted that this was to be implemented for all residents by September. We found that records were in a state of flux as some had been transferred to the new organisations system whilst others remained unchanged. Much of the work from the previous system had become lost and there was potential to overlook service users needs. The following recommendation made in the last inspection report is not met and now a requirement. The Manager and senior staff should ensure that service should review staff practice in relation to accident/incident recording and the management of falls. There should be sufficient numbers of staff on duty to ensure that health and well-being of service users is not compromised or restricted. ACTION TAKEN There was a policy and procedure for accident and incident recording and fall management. A range of risk assessments had been undertaken for individual service users. These all contained information in the assessment and review of clinical needs. However, where needs had been identified, strategies to minimise risk were not always apparent and care plans had not been updated to monitor any changes. The recording of falls and accidents was inconsistent and lacked accountability. For example, in personal records of a service user, we noted that falls had been recorded. However, these were missed in the monthly auditing of falls and did not accurately reflect any re-assessment or preventative measures. In addition, moving and assisting practice and communal use of slings is poor and compromises safety. (See Quality Statement 2.2 for further information). Given concerns raised about dependency assessments, we consider that the service should review and be pro-active in how they manage moving and assisting, falls and fractures taking account of the Managing falls and fractures in care homes for older Belhaven House, page 21 of 45

22 people published by Social Care and Social Work Scotland (SCSWIS) 2011 and NHS (See Requirement 4 of this Quality Statement) We observed meal times and spoke with residents about the quality of food. However, the meal time experience has deteriorated and service users told us that: "No longer get regular home baking" "No fresh fruit is offered" "I just take whatever is given to me" "We get puddings that are easy to make" We found that the menus had changed and no longer reflected service users' choices. We observed meal time experiences to be poor for residents. For example, people were waiting for long periods of time before being served their meal and left sitting for overly lengthy times after meals, menus were no longer displayed so people did not know what they were being served. (See Requirement 5 of this Quality Statement) We looked at medication procedures and Medication Administration Records (MAR). We found that where there were handwritten amendments, these were authorised and accountable and there has been improvement. However, we also noted that some supplies of medication did not cover one month. We were informed that, even though the service had requested medication, there can be a delay between the prescribing GP and dispensing pharmacy. However, the service must ensure that there is sufficient stock so service users are not without prescribed medication at any time. (See Requirement 6 of this Quality Statement) Grade awarded for this statement: 1 - Unsatisfactory Number of requirements: 6 Number of recommendations: 0 Requirements 1. The Provider must ensure that all staff are fully aware of all service users' status under the Adults with Incapacity (AWI) Act. The service must review individual service user's capacity to make informed decisions, and, where necessary, introduce appropriate Certificates of Incapacity. In addition, the service should review the policy in relation to the use of restraint and ensure that staff are clear about and implement Guidance from MWC. This is in order to comply with: Inspection report continued Belhaven House, page 22 of 45

23 SSI 2010/210 Regulation 4(1)(a): a requirement to make proper provision for health, welfare, and safety of service users. This is to comply with SS1 2011/210, Regulation 4. (1)(a) - a requirement to make proper provision for the health and welfare of service users and Regulation 5. (1) (c) - Personal Plans This should also take account of: National Care Standards, Care homes of older people, Standard 6: Support arrangements. Timescale for implementation: within three months of receipt of this report. 2. The Provider must ensure that staffing levels are appropriate to meet the health and wellbeing needs of service users. Staffing levels should take account of the needs of service users and the physical layout of the building. This is in order to comply with SSI 2010/210 Regulation 4(1) (a): a requirement to make proper provision for health, welfare, and safety of service users Timescale for implementation: within 4 weeks of receipt of this report. 3. The Provider must be able to evidence that they have reviewed and updated care plans based on best practice and improved outcomes for service users. In order to do this the provider must: a) Improve the assessment and care planning process for residents by; ensuring that all care needs are identified and that appropriate up to date care plans are in place. In addition, the Provider must ensure that care plans reflect the current assessed needs of residents in line with best practice guidance and evidence how the plan is being followed on a daily basis. b) The provider must improve the standard of record keeping within the range of documentation within the home in particular the resident's care plan. The provider must ensure that the personal care needs of residents are met at all times. Particular attention must be paid to care issues such as falls risk assessments, continence management, nutrition and social and psychological wellbeing of residents. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) SSI 2011/210 Regulation 4(1) (a) Welfare of users. SSI 2011/210 Regulation 4(1)(b) - a requirement to provide services in a manner which respects the privacy and dignity of service users. SSI2011/210 Regulation 5. (1)(c)- Personal Plans Belhaven House, page 23 of 45

24 Timescale for implementation: within 3 months of receipt of this report. 4. The service should review staff practice in relation to accident/incident recording and the management of falls. Records should evidence that they have reviewed, updated care plans and implemented appropriate measures based on best practice. Particular attention must be paid to care issues such as falls risk assessments and management and prevention of falls. There should be sufficient numbers of staff on duty to ensure that health and well-being of service users is not compromised or restricted. This is in order to comply with SSI 2010/210 Regulation 4(1) (a): a requirement to make proper provision for health, welfare, and safety of service users National Care Standards, Care homes of older people, Standard 6: Support arrangements. Timescale for implementation: within 4 weeks of receipt of this report. 5. Food and fluid provision must meet the needs of residents. To do this the provider must: - review the policy and procedures for the management of food, fluid and nutritional care of residents and ensure that these are fully implemented within the home in accordance with best practice guidance. - ensure that each residents eating, drinking and dietary needs and preferences are assessed on admission and on an ongoing basis. - ensure that residents have an eating, drinking and nutritional care plan based on their needs. This should contain sufficient detail of the actions to be taken to address identified needs. - ensure that menu planning is based on best practice guidance and is based on a needs assessment of residents. - ensure that residents are consulted at the development stage of menu planning and on an ongoing basis. - ensure that residents fluid needs are met and that fluids are actively promoted. - ensure that residents get the help that they need to enjoy their food. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. National Care Standards Care Homes for Older People Standards 5.4, 6, 13, and 14. Timescale: Within 24 hours from the date of issuing this report. Belhaven House, page 24 of 45

25 6. The service must improve their medication ordering systems to ensure that there is sufficient stock of medication that so service users are not without prescribed medication at any time. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. National Care Standards for older people - Standard 15- medication. Timescale: On receipt of this report. Inspection report continued Belhaven House, page 25 of 45

26 Quality Theme 2: Quality of Environment Grade awarded for this theme: 1 - Unsatisfactory Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths The grade awarded for this Quality Statement at the last inspection on 8 November 2013 was 4 - Very Good. The evidence we sampled at this inspection has lowered this grade to 2 - Weak. Also see comments under Quality Statement 1.1 Residents interviewed stated that they were supported to personalise their own rooms. The bedrooms the Inspectors visited were personalised differently according to the wishes of the resident and personal photographs added to the sense of ownership. The communal areas were well furbished. Signage had been used to direct people with cognitive impairment to identify areas such as toilets. Areas for improvement See areas for development identified under Quality Statement 1.1 in relation to service user participation. On days of inspection, atmosphere in care home was tense creating an uncomfortable atmosphere for residents. The service had improved the garden area so that service users could go out in good weather. However, there was no evidence to substantiate how the service can use the building both internally and externally to improve the quality of life of service users. In addition, the service should also consider how it enables service users to access the wider community. (See Recommendation 1 of this Quality Statement) The upstairs lounge was not in use during this inspection and we were informed that Belhaven House, page 26 of 45

27 the television had not worked for some time. This limited choice for service users who all congregated in the 2 downstairs lounges. The inspection in 2012 noted that they had ordered nameplates for each bedroom door so that visitors and service users could more easily identify their room more easily. This has been done and each bedroom door is also numbered. Despite these being in place, there is no additional benefit for people to help identify their bedroom door more easily. The service should consider enhancing and personalising these to make it easier for people with visual and cognitive impairment to identify their bedrooms more easily. The previous recommendation that the service should continue to develop opportunities for residents and carers to participate in assessing and improving the quality of the environment within the service and evidence how participation has led to service improvements is again repeated. (See Recommendation 2 of this Quality Statement). Grade awarded for this statement: 2 - Weak Number of requirements: 0 Number of recommendations: 2 Recommendations Inspection report continued 1. Consideration should be given to maximising the external and internal areas to improve the quality of life of service users. This should include community based resources. National Care Standards for care homes for Older People: Standard 4 - Your Environment. 2. Service users should be consulted about their environment in a meaningful way which promotes their rights to choice, privacy and dignity and enhances their quality of life. National Care Standard for care homes for Older People Your Environment. Statement 2 We make sure that the environment is safe and service users are protected. Service strengths The grade awarded for this Quality Statement at the last inspection on 8 November Good. The evidence we sampled at this inspection has lowered this grade to 1 - Unsatisfactory. Belhaven House, page 27 of 45

28 Issues relating to health and well-being identified in quality statements are relevant to this quality statement. The service has policies and procedures in place to support this quality statement. There were policies which were carried out on matters of health and safety and records were maintained for accidents/incidents. (See Quality Statement 1.3 for further information about accident/incident recording and falls management) There was a system in place for reporting repairs. There was a secure door entry system and sign in/out system for visitors to the home which contributed to a safe environment. Information and risk assessments regarding the safety and security of residents and staff were in place. Areas for improvement We found that inadequate staffing levels/deployment of staff seriously compromised the safety of residents. During inspection, we observed that: * The standard of housekeeping was poor in some areas such as the bathroom. * The carpet at the top of the staircase was loose and posed a trip hazard. * The corridor leading from front entrance to the small kitchen utility room was not kept locked throughout the inspection. * The sinks in the kitchen utility room were stained and appeared dirty. * Some bedrooms had a strong odour of urine. * Cups and crockery were in a poor state as some were stained, appeared unclean & chipped. * Poor cleaning schedules compromised infection control and health and well being. All of the above raised the risk of the spread of infection and we observed that there were poor infection control practices in place. (See Requirement 1 of this Quality Statement) We found that the bathroom on the ground floor to be in an unacceptably poor state. We had noted concerns in our inspections in Subsequently, we reported that the provider had replaced the boiler and had made minor decorative improvements. However, at this inspection, the same bathroom had a very strong unpleasant smell, we found debris, slippers and slings discarded in a corner, broken bath tile, a shower Belhaven House, page 28 of 45

29 chair to be rusting and unclean and unidentified matter on the bathroom floor. As this is the only bathroom the service has, it compromises choice for service users who may wish to have a bath rather than a shower. The provider has repeatedly failed to improve this bathroom and we have now made a requirement. The provider has again stated his intention to upgrade this bathroom. (See Requirement 2 of this Quality Statement) The service had external contractors to regularly check and maintain health and safety equipment such as hoists and lifts. However, the internal system for reporting and following up on repairs did not demonstrate clear lines of responsibility and accountability and seriously compromised the health and safety of residents. For example, we found that although external maintenance checks had repeatedly raised concerns about some slings, they continued to be used and condemned shower chairs were not cleaned, rusting and were still being used. The service has a handyman. However, obvious repairs were not reported by staff. For example, a fan in an en-suite bathroom needed attention although staff had not reported it for repair. We consider that the provider, manager and staff should be more pro-active in addressing health and safety matters from a service user's perspective and re-enforce to all levels of staff their responsibility to report any potential hazards and repairs. We found that this was not happening and consider that the service needs to promote and ensure that all staff practice ensures that service users are protected from avoidable risk of harm, including physical harm and infection. (See Requirement 3 of this Quality Statement) The distance between communal areas and some bedrooms is particularly long for people with mobility difficulties. As a result, the users were reliant on staff assistance to enable them to access some areas of the building. During inspection, no-one was observed going to their bedroom on their own. The Provider, manager and staff should consider how they assist service users to access all areas with ease. The layout of the premises is disorientating, particularly for people with disabilities and cognitive impairment. The manager and staff should consider ways to improve and maintain a safe environment for people with cognitive impairment. We have seen no further progress and will monitor progress. We found that the service did not offer a sufficient open door policy, nor supported a complaints system and whistle blowing procedure all of which did not contribute to producing and maintaining a safe environment for residents. We experienced hostility during inspection and gained the impression that staff and residents were discouraged from participating in this inspection. (See Quality Statement 4.4 for further information) Inspection report continued Belhaven House, page 29 of 45