Care service inspection report

Transcription

1 Care service inspection report Full inspection Abbey Gardens Nursing Home Care Home Service Lincluden Road Dumfries Inspection completed on 26 November 2015

2 Service provided by: Voyage 1 Limited Service provider number: SP Care service number: CS Inspection Visit Type: Unannounced Care services in Scotland cannot operate unless they are registered with the Care Inspectorate. We inspect, award grades and set out improvements that must be made. We also investigate complaints about care services and take action when things aren't good enough. Please get in touch with us if you would like more information or have any concerns about a care service. Contact Us Care Inspectorate Compass House 11 Riverside Drive Dundee DD1 4NY enquiries@careinspectorate.com page 2 of 38

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 Quality of environment 4 Quality of staffing 4 Quality of management and leadership 4 Very Good Good Good Good What the service does well The staff team at Abbey Gardens always provide a warm and friendly welcome. This service benefits from a consistent team of staff who, have built up considerable knowledge of the residents and their individual needs. We received many positive comments from the residents and relatives we spoke to during our inspection visits; they expressed appreciation for the relaxed, welcoming atmosphere within this care home. What the service could do better The service needs to continue to develop the content of the support plans system. We saw examples of good work within the documentation and the service needs to continue to develop this. The service needs to ensure that all staff have the appropriate level of training in dementia, which is reflected against the Scottish government framework for excellence modules. page 3 of 38

4 The provider needs to invest in the general fabric and condition of some of the areas within the home. There is much potential in this building that could be further enhanced. What the service has done since the last inspection The service has addressed any requirements and recommendations in previous inspection reports. The manager and deputy are keen to keep abreast of best practice guidance and are motivated to implementing changes within the care home to improve the overall care experience for their residents. As much as they can within their capabilities and resources, they have sought to make changes within the care home environment. This needs further investment from the provider to make a real difference. Conclusion Abbey Gardens continues to provide an overall very good standard of care and support to the people who live there. The quality of the friendly care and support provided by the staff team has been widely praised by people we spoke. page 4 of 38

5 1 About the service we inspected Inspection report 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 Abbey Gardens is a purpose built care home situated in Lincluden on the outskirts of Dumfries, close to local facilities and on a major bus route to Dumfries town centre. The home provides 24 hour nursing care and accommodation for up to 32 older people with complex mental health needs and associated sensory and physical disabilities. These disabilities may be complex and include enduring health conditions and behavioural support. The service states that, we make sure that day to day home living, recreation and socialising are all part of everyday life at the service. We have established links with the local community and take advantage of the facilities available, with service users regularly using the hairdresser, café, shops and resource centre. The service aims are "to provide a safe environment for those who have enduring mental health problems and require a high level of support, whilst still recognising that these individuals have the right to a life style that is happy, dignified and reflects the concept of normalisation so that the residents are seen as valued individuals within the community". The service provider is Millbury Care Services Ltd trading as Voyage. The service is located in a residential area close to a range of small shops and other local community facilities and provides a permanent residential service for older people who have mental health support needs (both organic and functional) and some associated sensory and physical disabilities. These disabilities may be complex and include enduring health conditions and behavioural support needs. The home consists of four units, each providing accommodation and support for eight residents according to their assessed need. page 5 of 38

6 The service is comprised of four separate units within one building, surrounding a central reception area. Each unit has eight ground floor single bedrooms with en-suite facilities, which are fully accessible and specifically designed for people with mental and physical health needs. There are communal rooms in each unit including a lounge, a kitchen, a dining room and a shower/bathroom. All of these rooms have been designed with the service user in mind. Each unit is fully equipped to deliver support and care, providing an environment able to meet any support needs on an individual level. In addition, the service has a large reception area, an activity room, a central kitchen where the cook prepares meals and snacks and a laundry with dedicated laundry staff. There is also a very large, enclosed, sensory garden with patio areas and a greenhouse. Recommendations A recommendation is a statement that sets out actions that a care service provider should take to improve or develop the quality of the service, but where failure to do so would not directly result in enforcement. Recommendations are based on the National Care Standards, SSSC codes of practice and recognised good practice. These must also be outcomes-based and if the provider meets the recommendation this would improve outcomes for people receiving the service. Requirements A requirement is a statement which sets out what a care service must do to improve outcomes for people who use services and must be linked to a breach in the Public Services Reform (Scotland) Act 2010 (the "Act"), its regulations, or orders made under the Act, or a condition of registration. Requirements are enforceable in law. We make requirements where (a) there is evidence of poor outcomes for people using the service or (b) there is the potential for poor outcomes which would affect people's health, safety or welfare. Based on the findings of this inspection this service has been awarded the following grades: page 6 of 38

7 Quality of care and support - Grade 5 - Very Good Quality of environment - Grade Quality of staffing - Grade Quality of management and leadership - Grade Inspection report 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. page 7 of 38

8 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 undertaking unannounced inspection visits on the following days; Monday 23 November 2015, we met with the nurse in charge and conducted a walk round of the care home environment, observing the daily interactions and talking with residents, relatives and staff. Tuesday 24 November 2015, we met with the manager and discussed the progress the service had made since the last inspection. We reviewed the recruitment documentation, staff support and supervision documentation and the care planning folders. Wednesday 25 November 2015, we met with the deputy manager and reviewed the maintenance procedures. Thursday 26 November 2015, we met with the manager and provided feedback and awarded grades for the various quality statements we were inspecting against. During these inspection visits, we checked the following documentation. - Registration certificate - Employer's liability insurance - Participation strategy - Abbey Gardens newsletter July/August Annual service review October/November Minutes of residents meetings - Minutes of relatives meetings page 8 of 38

9 - Minutes of staff meetings - Care Plans and review meetings - Risk assessments - Staff training records - Staff supervision schedule - Staffing rotas and numbers - Adult support and protection procedures - Medication records - Maintenance records - Accident and incident records - Notifications - Self-assessment return - Annual return - Care Inspectorate questionnaires During these inspection visits, we spoke to the following people: - Five residents - Four relatives - Two nurses - Seven care staff - One manager - One deputy manager We spoke to the new operations manager by telephone after the inspection and updated them on the grades we had awarded and the areas for development identified. We looked at the comments and feedback from residents, relatives and staff in their returned Care Inspectorate questionnaires. We reviewed the content and comments in the returned Care Inspectorate questionnaires. We received four from residents and two from relatives and eight from staff. When asked overall if they were happy with the quality of service provided. Two page 9 of 38

10 residents strongly agreed and one agreed with this statement and one stated they did not know. We received only two completed questionnaires from relatives both strongly agreed that they were overall happy with the quality of care the home provided. One wrote: "My relative has been a resident for many years and has enjoyed a very high standard of care throughout their stay, always appropriate to his needs we can relax and know they are in safe and happy. Our family are always welcomed here. Perfect". We received eight complete questionnaires from staff. Their responses indicated a satisfied team of staff, one commented: "The home has provided me with all the training and support needed". Inspection report We reviewed the feedback from the service's annual review from residents, relatives and staff. Some of their written comments are included in this report. 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. page 10 of 38

11 Fire safety issues Inspection report 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 page 11 of 38

12 The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self assessment document from the service manager. The service had identified what they thought they did well, and some areas for development. Taking the views of people using the care service into account From the information we received in Care Inspectorate questionnaires, the service satisfaction survey and from talking to residents we have included their opinions, Resident's comments included: "All care is available and friendly, the relaxed and friendly atmosphere is much appreciated". "The staff are excellent and they are friendly and reliable". "The support I have received has been very good". "Really good, I enjoy and like being at Abbey Gardens". When asked: "What is best about living at Abbey Gardens", residents comments included: page 12 of 38

13 "The garden and being able to look at the flowers and birds". When asked for their ideas and suggestions some included: "Meals to change for the better". Taking carers' views into account From the information we received in Care Inspectorate questionnaires, the service satisfaction survey and from talking to relatives we have included their opinions, Relative's comments: "My relative has been a resident for many years and has enjoyed a very high standard of care throughout their stay, always appropriate to his needs we can relax and know they are in safe and happy. Or family are always welcomed here. Perfect". "My relative says 'the staff are wonderful' which is very reassuring to hear they are knowledgeable and friendly. It is helpful to get the newsletters as we live further away. So far we are very pleased". "The staff are friendly and caring throughout and I have always found everyone very helpful". "Any queries I have had are always answered and people seen prepared to go that extra mile". "The staff are very caring and supportive, I am very happy with the care my relative receives". "More home cooking and different options instead of the same food". page 13 of 38

14 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths After we had reviewed the evidence and information gathered during our inspection visits, we decided the service had maintained a very good standard of participation under this quality statement. The overall atmosphere throughout the home was warm, friendly, and welcoming. The service had completed an annual service review in October/November 2015 and we reviewed the information and feedback received from residents, relatives and service users. We noted that the service had developed pictorial questionnaires to assist people to communicate their opinions effectively. The manager reviewed the feedback received in the service's survey and completed action plans under; What's Working and What's Not Working, with headings for outcomes, actions and identifying who was responsible for these actions and timescales for when they will be achieved. This was a good example of participation and one that influenced our decision to maintain this grade. It would have been good to have a similar response in page 14 of 38

15 the number of returned Care Inspectorate questionnaires; unfortunately, the number of replies we received was small. During our inspection visits, we spoke to residents, relatives, various members of staff. We reviewed the relevant documentation the service presented to support the strengths of this quality statement. From the care and support plans we reviewed we could see residents and relatives were involved in the process of discussing, developing and agreeing the content of this documentation. We looked at the comments and responses from Care Inspectorate questionnaires completed by residents, relatives and staff. The responses were positive and encouraging, however limited in number. The residents we met during our visits expressed a great deal of satisfaction with the standard of the service they received, in particular special mention and positive comments about the staff team. Relatives we spoke to during our visits commented highly on the quality of the staff team and how confident they felt with the care and support provided. Relatives told us they were involved and welcomed when they visited, which helped to make the visiting experience a pleasant one. We saw that residents were involved in the decoration and personalisation of their bedroom areas. This gave people a sense of their own personal space. We sat and spoke to one resident whose bedroom has a nice view of the garden. Staff had hung up bird feeders and the gentleman enjoyed sitting in his room reading his papers and watching the birds. Relatives meetings took place and we noted from the minutes this included feedback on the quality of the care and support provided. The manager and deputy used this information to assist with the supervision and supporting the staff team. page 15 of 38

16 Residents meetings were organised and we saw that discussions included, arranging the Christmas party in a local public house, which was good to see the home making connections within the local community by encouraging engagement. The entrance foyer had notices regarding the menus and meal suggestions or preferences and this would be purchased. There was a notice board with detailing, "You Said We Did", referring to comments or suggestions and how the service had responded. The manager writes a regular newsletter and s or posts this out to relatives keeping them updated on events within the care home, relatives appreciated this contact. She also keeps a folder of compliments and complaints, with a record of interactions with relatives regarding any issues raised and the responses given. This helps to ensure people feel able to participate in the development and improvement of the service. Areas for improvement The service should continue to maintain the very good standards they have achieved under this quality statement. They should continue to evidence how they ensure residents and relatives are kept involved in the developments within the service. The manager and staff should encourage residents, relatives and staff to complete future Care Inspectorate questionnaires as this helps to provide evidence to support the good work they are doing within the service. Grade 5 - Very Good Number of requirements - 0 Number of recommendations - 0 Inspection report page 16 of 38

17 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths After we had reviewed the care and support planning documentation and spoke with residents, relatives, staff and the managers, we decided the service had continued to maintain a very good standard in addressing the health and well being needs of the residents. During our inspection visits, we spoke to residents, relatives, various members of staff. We reviewed the relevant documentation the service produced to support the strengths in this quality statement and we looked at the questionnaires completed by residents, relatives and staff had returned to the Care Inspectorate. The manager completed a monthly dependency tool, which details the varying levels of need of the residents. This ensures the service maintains the appropriate staffing levels to meet the needs of the residents. We reviewed the care and support plans and saw that staff had implemented proper procedures to meet any identified needs highlighted by the various health assessments utilised. This included referrals to medical or health professionals. The care and support planning documentation was set out in two colour coded folders, one covering all health assessments and regular observations and one for all care and support plans. The folders we inspected were well presented and organised with information easily accessible in each section. Staff signed the front sheet to say they had read and understood the content of the folders. This ensured that anyone delivering support to residents was aware of their identified health and well being needs, including how to deliver appropriate care and support to them. page 17 of 38

18 We witnessed the nursing staff communicating with District Nurse regarding flu vaccinations and the care plan documentation we inspected showed very good communication and follow up of any subsequent treatment regimes prescribed. The deputy manager we met with demonstrated a very good knowledge and professional expertise in the management of individuals with mental health backgrounds. We saw very good liaison with professionals from the mental health teams including the consultant psychiatrists. The service managed to provide a very good standard of care to those individuals with complex and challenging needs including advanced dementia. The overall relaxed and comforting atmosphere throughout the care home environment assisted this. We noted that some care plans, nursing staff had completed to a very good standard with background histories, personal contact details and clear explanations of the type of support and assistance each person required. Relatives we spoke to expressed their satisfaction with this level of support and felt confident in how the service addressed the physical and mental well being of the residents. There is a monthly medication audit completed to identify any issues or concerns. The service has provided staff with various training opportunities. We reviewed the medication recording sheets. We were satisfied the service had implemented appropriate procedures to ensure residents got the correct medication at the proper times. We saw staff interacting with residents in addressing their health and well being needs. Staff provided this support in a dignified and respectful manner. We received many positive comments about the way staff engaged with the residents. The feedback from relatives indicated a very good standard of communication by keeping them informed of any health related issues and the progress of any subsequent interventions. page 18 of 38

19 We sat in on the staff handover during an afternoon shift changeover; we saw a very good level of interaction and communication between the nursing and support staff. They clearly knew their residents well and could provided detailed personal knowledge of any on going health issues. The manager and deputy are in the process of developing new booklets that will present the personal life histories of the residents. This will involve the residents and their relatives using photographs and other information to promote the person centred approaches within the service. People we spoke to during our visits were very happy with the standard and quality of the meals provided. Alternatives were on offer if people changed their minds or wanted something different to the planned menu. Residents and relatives helped to complete lists of food they would like or dislike. Areas for improvement Recommendation 1 Nutritional needs of residents The manager needs to ensure that the nutritional needs of residents are met and the offering of varied menu with fresh content and regular choices the menus we viewed needed to be developed to include more fresh vegetable and fruit. We inspected the kitchen larder and found an over reliance on processed tinned products and packet cakes and biscuits. National Care Standards for Older People Standard 13 - Eating well. Recommendation 2 Activities programme The manager needs to develop the activities programmes on offer within the service. This could include the investigation of an identified individual to take the lead role and develop the activities programme available to the residents. This would help to enhance the lifestyle opportunities within the service. National Care Standards for Older People - 17 Daily Life. Inspection report Where there is a need for medication as required then an appropriate 'PRN Protocol' should be written up with the clear descriptions of the reasons and page 19 of 38

20 when this should be administered. The manager and staff should continue to develop the support plan documentation to ensure that this is person centred in approach and is up to date, accurate with the descriptions, and content. This should include the continued development of the personal histories booklets that were in the early stages of progress. Grade 5 - Very Good Number of requirements - 0 Recommendations Number of recommendations Nutritional needs of residents The manager needs to ensure that the nutritional needs of residents are met and the offering of varied menu with fresh content and regular choices the menus we viewed needed to be developed to include more fresh vegetable and fruit. We inspected the kitchen larder and found an over reliance on processed tinned products and packet cakes and biscuits. National Care Standards for Older People Standard 13 - Eating well. 2. The manager needs to develop the activities programmes on offer within the service. This could include the investigation of an identified individual to take the lead role and develop the activities programme available to the residents. This would help to enhance the lifestyle opportunities within the service. National Care Standards for Older People - 17 Daily Life. page 20 of 38

21 Quality Theme 2: Quality of environment Grade awarded for this theme: Statement 2 We make sure that the environment is safe and service users are protected. Service strengths After we had reviewed the maintenance records including health and safety procedures we decided the service had achieved a good standard in ensuring there was a safe environment and residents are protected. The home is secure by entry through keypad and all individuals entering the building have to sign the appropriate register. This ensures everyone within the building is accounted for. During our inspection visits, we reviewed the following documentation relating to maintaining a safe environment: - Registration certificate - Insurance certificate - Accident and incident records - Notifications to the Care inspectorate - Adults with incapacity documentation - Risk assessments - Repairs and maintenance records - Prevention of falls - Medication administration records - Staff training records We inspected the home environment and conducted a walk round. We found the home to be clean, tidy and well presented. The improvements we noted in the activity room and the addition of hairdressing salon style mirrors and chairs, page 21 of 38

22 which helped to create a nice space for residents to have their hair done. The domestic staff demonstrated a good knowledge of infection controls issues. They were committed to maintaining good standards of hygiene and cleanliness throughout the home and took pride in their work. We saw that there were systems in place to keep the environment safe and residents protected. Staff had training in health and safety, infection control, food safety, fire safety, moving and handling and adult support and protection. Staff we spoke with could demonstrate good knowledge of how to keep the environment and people safe. We noted that staff, residents and relatives could report repairs or concerns and the maintenance person would address these. We saw that appropriately qualified contractors serviced the moving and handling equipment according to guidelines and best practice. This ensured that any equipment used for residents was functioning properly and safe to use. We also noted that there was a very good attitude towards residents who wander, for example, having access to wander freely in the large communal foyer area of the home and accessing the secure garden areas. This gave people a sense of freedom and helped to reduce anxieties, agitation, whilst encouraging, and maintaining physical independence and mobility. We noted that the regular checks undertaken with respect to the health and safety within the building are completed by the management, ancillary and care staff. The home only has access to a maintenance person to undertake general repairs and visits the home several times per week, as they are covering other homes in the area. Although we were satisfied with the standard of the health and safety checks we inspected, we would advise the provider to review this. Areas for improvement The service provider needs to review and consider some investment to enhance the general care home environment. We saw a great potential in developing areas of the home to make them more dementia friendly. The large foyer area as you enter the home was clean and tidy but this large open space has the potential to be much more. page 22 of 38

23 Any future developments and improvements should continue to involve the residents and relatives in this process and we were pleased to see a very good ethos of participation developing within the service. The manager needs to capitalise on the very good levels of satisfaction and participation from residents, relatives and staff. Although we were satisfied with the standard of the regular maintenance checks that are at present completed by the managers and staff. The provider needs to review this due to the amount of time that is taken away from direct care. Grade Number of requirements - 0 Number of recommendations - 0 page 23 of 38

24 Statement 3 The environment allows service users to have as positive a quality of life as possible. Service strengths After we reviewed the evidence and information regarding this quality statement, we decided the service had achieved a good standard. During all our visits, we spent some time in each unit of the building and in the large communal area. We spoke to several residents and observed engagement and interaction between the residents and staff. We saw that the small eight bed units helped to create spaces that are more intimate and the staff got to know each of the residents very well. The bedrooms we looked at were clean tidy and personalised. We found the home environment to be very clean and tidy; the lounges were comfortable, warm and welcoming. We spent time sitting talking with residents who enjoyed using the lounges, there was a relaxed and friendly atmosphere for residents to engage with each other, staff and visitors. Relatives commented on how nice it was visiting the home and spending time with their relatives. Residents could decorate and furnish their bedrooms to their own style and choice. We observed several residents with advanced dementia's freely wandering between the units and around the large communal open space between the units. Staff told us this helped to give people an opportunity to exhibit behaviours that helped to calm them and alleviate anxieties. page 24 of 38

25 Areas for improvement We noted that within some of the units, some residents with high dependency needs spent a lot of time in their bedroom, whilst we met and spoke to residents in their rooms who were happy doing this. We would advise the manager to ensure that residents with high dependency needs are not left alone for long periods and there are opportunities for engagement. Grade Number of requirements - 0 Number of recommendations - 0 Inspection report page 25 of 38

26 Quality Theme 3: Quality of staffing Grade awarded for this theme: Statement 2 We are confident that our staff have been recruited, and inducted, in a safe and robust manner to protect service users and staff. Service strengths After we had reviewed the service recruitment procedures and documentation, we decided the service had achieved a good standard for this quality statement. The manager used an electronic system with regards the recruitment procedures. This helps to ensure that all the relevant elements are completed prior to anyone being employed. The system will not allow further progress until every part of the recruitment process has been completed to a satisfactory standard. The manager and deputy have a full understanding of the operation of this system. The service had implemented appropriate policies and procedures with respect to the recruitment and induction of staff. The manager and deputy had a well organised and thorough grasp of their responsibilities to ensure that all relevant documentation was in place prior to anyone working with residents in the care home. We checked several staff files and noted that the appropriate checks included. Application forms, two references one from the most recent employer and police or PVG certificate (protection of vulnerable groups). We saw in place all registration requirements with appropriate professional of regulatory bodies including the NMC Nursing and Midwifery Council for registered nurses and the SSSC Scottish Social Services Council for all other care and ancillary staff. page 26 of 38

27 The staff files we sampled evidenced good recording of interview procedures including induction programme for new employees. Areas for improvement The service should continue to implement the good standards they have achieved under this quality statement. The service needs to continue to maintain the standards of training and supervision of the staff team to ensure that they are competent and able to support the residents and meet their needs. Grade Number of requirements - 0 Number of recommendations - 0 Inspection report page 27 of 38

28 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths After we reviewed the staff training records and documentation, spoke to various members of the staff team we decided the service had achieved a good standard for this quality statement. We observed very good engagement between residents and staff and there was clear respect and dignity shown to residents during these interactions. Staff presented as being dedicated and they clearly knew their residents well. We reviewed the staff training records and noted that the manager and deputy manager ensured that staff had undertaken training covering areas of pressure sore assessment, moving and handling, medication administration, challenging behaviour, We reviewed the staff records and inspected the training, supervision and appraisal documentation. Staff we spoke to demonstrated a strong commitment to ensuring they provided residents with the necessary support required. Residents and relatives expressed a great deal of satisfaction with the quality of the staff. We checked several weeks of rotas and the staff on duty throughout the day and night. We were satisfied that the service had maintained agreed staffing levels required to meet the needs of the residents. From discussions with residents, relatives and feedback we received in returned Care Inspectorate questionnaires there was a great deal of satisfaction with the quality and standard of the staff team. They described the staff team as friendly, welcoming and helpful. Some written comments included: page 28 of 38

29 "My relative says 'the staff are wonderful' which is very reassuring to hear they are knowledgeable and friendly. It is helpful to get the newsletters as we live further away. So far we are very pleased". "The staff are friendly and caring throughout and I have always found everyone very helpful". There was a strong sense of commitment and team spirit evident. Staff told us they liked working in the home and felt they had a good team that helped each other out for the benefit of the residents in the home. The manager and deputy manager delivered training to the staff team. including safe handling of medications, challenging behaviour and fundamentals of nutrition. Each member of staff has their own training folder with a training log, the manager and deputy ensure that all staff had their mandatory training requirements addressed and updated as required. The manager conducted meetings for staff; we reviewed the minutes and saw staff had contributed to the developments within the home. The staff team worked well together and there was a good level of communication and interaction to ensure that resident's needs were met appropriately. Areas for improvement The manager should investigate and utilise external training opportunities for all levels of staff. This will further enhance the skills and knowledge of the staff team and help to develop people within their job roles and responsibilities. This should include the collation of verified training certificates and documentation to evidence and support this has been undertaken. The service is investigating various e learning courses and other distance learning programmes. This would help to compliment the existing training opportunities currently available to the staff team. The service needs to ensure they are implementing dementia training for all staff, based round the Scottish Government framework for excellence modules. page 29 of 38

30 The manager has already started to implement this programme of training and should continue with this positive progress. Grade Number of requirements - 0 Number of recommendations - 0 Inspection report page 30 of 38

31 Quality Theme 4: Quality of management and leadership Grade awarded for this theme: Statement 2 We involve our workforce in determining the direction and future objectives of the service. Service strengths After we had spoken with various members of staff and reviewed the evidence and information provided during our inspection visits, we decided the service had achieved a good standard for this quality statement. The manager and deputy implemented various procedures to enable staff to express their views or comments and get involved in the development of the service such as; staff meetings, open forums, questionnaires and staff supervisions and appraisal. Staff told us that communication and teamwork within the service was good. Areas for improvement The service should continue to develop the staff team and use them to gain ideas and suggestions for the developments within the service. This could include identifying individuals who can champion various aspects of the service. The service should use information from the self assessment and quality assurance processes to develop the service improvement plan showing how they plan to move the service forward in the coming months. This should be done in consultation with residents, relatives, staff and other stakeholders. page 31 of 38

32 My home life is a UK-wide initiative that promotes quality of life and delivers positive change in care homes for older people. The provider should consider introducing this approach to the care homes. For further information contact, Grade Number of requirements - 0 Number of recommendations - 0 page 32 of 38

33 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 spoke with the manager and deputy; we reviewed the quality assurance documentation in place within the service. After we reviewed the evidence and information provided, we decided the service had achieved a very good standard for this quality statement. We observed good interactions with the manager and the deputy with professional respect shown in their working practices. This helped to support the good work of the staff team and help the service to gel together. There was an open door policy in place and people we spoke to commented that both the manager and deputy were approachable and helpful. Relatives we spoke to confirmed they felt able to raise issues or concerns about the service and these would be addressed. We saw that the service had used several methods including residents and relatives meetings, satisfaction surveys, telephone contacts and s to capture information and gather feedback from residents and relatives about the quality of the service. The manager used this information to help make changes and developments within the service. The manager and deputy conducted regular meetings with residents and relatives to help them voice their opinions and provide feedback on how satisfied they were with the quality of the care and support provided. As a result, people felt able to speak up and make suggestions that led to improvements in the service. This inclusive style, encouraged people to take part in ensuring the service continued to develop. The manager and deputy utilised a number of electronic quality assurance and key indicators for the completion of audits and recording the activity within the page 33 of 38

34 care home. The manager and deputy have a number of computer based software packages based round the quality assurance procedures and information data recording to allow and assist with the analysis of activities within the care service. These include payroll, rotas, absence management, holiday, staff supervision, appraisal and training recording, accident and incident records, recruitment procedures. These systems allow the manager and deputy to analyse and review the various elements within the service and help to identify areas for development and improvement. We reviewed several of the quality assurance systems in place such as, medication administration, accident and incident recordings and environmental. We saw that manager had undertaken to review the information from these audits and this resulted in changes and improvements they had implemented. We found that a variety of quality assurance processes and systems in place to assess and improve the quality of service. Quality monitoring systems in place included: - Audits of questionnaires - Feedback from meetings - Direct observation and feedback of staff competencies - Evaluation of comments and complaints - Supervision and support for staff - Performance appraisal for staff. - Feedback from other professionals - Feedback from residents and carers Areas for improvement The manager and deputy should continue to develop and maintain the very good standard of quality assurance procedures they have implemented. They should continue to maintain and document the evidence and information with respect to ensuring that residents and relatives can contribute to assessing the quality of the management and leadership of the service. This should also include how any of this information is utilised to implement any changes in page 34 of 38

35 response to feedback they have received. The service should include feedback from other health professionals and stakeholders to assess and evaluate the quality of the service they provide. Grade Number of requirements - 0 Number of recommendations What the service has done to meet any requirements we made at our last inspection Previous requirements There are no outstanding requirements. 5 What the service has done to meet any recommendations we made at our last inspection Previous recommendations There are no outstanding recommendations. 6 Complaints No complaints have been upheld, or partially upheld, since the last inspection. page 35 of 38

36 7 Enforcements We have taken no enforcement action against this care service since the last inspection. Inspection report 8 Additional Information There is no additional information. 9 Inspection and grading history Date Type Gradings 27 Nov 2014 Unannounced Care and support 5 - Very Good Environment Staffing Management and Leadership 5 - Very Good 12 Dec 2013 Unannounced Care and support Environment Staffing Management and Leadership 11 Jan 2013 Unannounced Care and support Environment Staffing Management and Leadership 8 Sep 2011 Unannounced Care and support Environment Staffing Not Assessed Management and Leadership Not Assessed 24 Jan 2011 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed page 36 of 38

37 Management and Leadership Not Assessed 30 Sep 2010 Announced Care and support Environment Not Assessed Staffing Not Assessed Management and Leadership 2 Nov 2009 Unannounced Care and support 3 - Adequate Environment Staffing Management and Leadership 6 May 2009 Announced Care and support 3 - Adequate Environment Staffing Management and Leadership 3 - Adequate 22 Jan 2009 Unannounced Care and support Environment Staffing Management and Leadership 12 May 2008 Announced Care and support 3 - Adequate Environment Staffing 3 - Adequate Management and Leadership 3 - Adequate page 37 of 38

38 To find out more This inspection report is published by the Care Inspectorate. You can download this report and others from our website. You can also read more about our work online. Contact Us Care Inspectorate Compass House 11 Riverside Drive Dundee DD1 4NY Other languages and formats This report is available in other languages and formats on request. Inspection report Tha am foillseachadh seo ri fhaighinn ann an cruthannan is c?nain eile ma nithear iarrtas. page 38 of 38