Tor Christian Nursing Home Care Home Service Adults 30 Corstorphine Road Edinburgh EH12 6HP Telephone:

Transcription

1 Tor Christian Nursing Home Care Home Service Adults 30 Corstorphine Road Edinburgh EH12 6HP Telephone: Inspected by: Rose Bradley Type of inspection: Unannounced Inspection completed on: 13 February 2013

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 18 4 Other information 41 5 Summary of grades 42 6 Inspection and grading history 42 Service provided by: Tor Christian Nursing Ltd Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Rose Bradley Telephone enquiries@careinspectorate.com Tor Christian Nursing Home, page 2 of 44

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 3 Adequate Quality of Environment 4 Good Quality of Staffing 4 Good Quality of Management and Leadership 4 Good What the service does well Residents we spoke with told us they were happy with the care they received. Residents looked well cared for in their appearance and we saw that staff were attentive to their needs. Staff attended to residents' care in a respectful manner and in a way that showed they were familiar with residents' care needs and preferences. The environment was pleasant and there was a calm atmosphere. The gardens were beautifully maintained and appreciated by residents. The Bistro provided a welcoming and popular area for residents and visitors to meet socially. What the service could do better The service must continue to build on the improvements they have made so far if the overall quality of the service is to improve. The staff team needs to consolidate to make sure that a consistent standard of care is given at all times. The service needs to continue to work with staff to make sure they are all able to put into practice what they have learned from any training they receive. Care planning and record keeping must be improved. This is to ensure that the service can evidence that staff give care that is based on up to date information about the assessed need of each resident. Tor Christian Nursing Home, page 3 of 44

4 What the service has done since the last inspection Inspection report continued Since the last inspection the new manager had commenced in post. Recruitment for the last vacant posts was taking place. Residents and relatives were being kept updated about staff recruitment and changes to the staff team. We could see that the provider and new manager continued to support staff to make the necessary changes that would help improve the overall quality of the service. Some progress had been made toward meeting the requirements made at the last inspection. Conclusion The provider continued to be fully committed to improving the quality of the service. The provider was aware of the areas that need to be improved and was tying to make these changes in a way that would lead to sustained improvement at the service. Who did this inspection Rose Bradley Lay assessor: Mrs Dianne Howieson Tor Christian Nursing Home, page 4 of 44

5 1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Prior to 1 April 2011, this function was carried out by the Care Commission. Information in relation to 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 The Care Inspectorate will award grades for services based on findings of inspections. Grades for this service may change after this inspection if we have to take enforcement action to make the service improve, or if we uphold or partially uphold a complaint that we investigate. The history of grades which services have been awarded is available on our website. You can find the most up-to-date grades for this service by visiting our website, by calling us on or visiting one of our offices. Requirements and recommendations If we are concerned about some aspect of a service, or think it could do more to improve its service, 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. - A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reforms (Scotland) Act 2010 and Regulations or Orders made under the Act or a condition of registration. Where there are breaches of the Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Inspectorate. Tor Christian Nursing Home (referred to in the report as "the service") is a care home service registered to provide 24 hour care for up to 50 older people. There were 46 people (referred to as "residents" in the report) living at the service at the time of inspection. The service is owned and managed by Tor Christian Nursing Ltd (referred to in the report as "the provider"). The service is situated in a residential area toward the west of the city, not far from the city centre and close to main bus routes and local amenities. Accommodation is provided within a converted and extended detached villa, set in mature gardens with space for parking within the grounds. The accommodation is on two floors, with stairs and passenger lifts giving access to the upper floor. There are 42 single bedrooms, 30 of which have en suite facilities and four twin rooms. Shared toilets and bathrooms are also available on each floor. The service's philosophy of care states that the service aims to be "a place where (residents) are enabled to exercise choice" and "can continue to be as independent as they are able". Tor Christian Nursing Home, page 5 of 44

6 Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 3 - Adequate Quality of Environment - Grade 4 - Good Quality of Staffing - Grade 4 - Good Quality of Management and Leadership - Grade 4 - Good Inspection report continued 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. Tor Christian Nursing Home, page 6 of 44

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 The focus of this inspection was to measure progress in meeting the requirements and recommendations made following the last inspection of October This report should be read along with the report of October We wrote this report after an unannounced inspection that took place at the service on the 7 February 2013 between the hours of 10am and 5.30pm and the 13 February 2013 between the hours of 10am and 4.30pm. The outcomes of the inspection were discussed with the manager and chief executive on the 13 February The inspection was carried out by inspector Rose Bradley. Lay assessor Dianne Howieson was also present on the first day and spent six hours speaking with residents and relatives about what they think about the service. Lay assessors are members of the public who use a care service, have used a care service in the past or care for someone such as a family member or friend. They help us to get the views of people using the care service. The lay assessor's observations are incorporated into this report. During this inspection we gathered evidence from various sources, including the relevant sections of records and other documentation including evidence from: -The service's action plan to address the requirements and recommendations made following the last inspection - A sample of residents' personal plans/care plans - Minutes of staff, resident and relative meetings - Accident and incident records - Maintenance records - Observation of staff practice - Observation of staff interaction with residents and fellow workers - Examination of the environment and equipment - Medication administration recording system - Certificate of Registration - Public Liability Insurance Certificate - Consideration of residents and relatives comments made during the inspection. The lay assessor spent six hours speaking with residents and relatives about their experiences of the service. Tor Christian Nursing Home, page 7 of 44

8 - We took into account the Public Services Reform (Scotland) Act 2010 and associated Statutory Instruments, the National Care Standards, Care Homes for Older People, and the Scottish Social Services Council (SSSC) Codes of Practice for Social Service Workers and Employers. Discussion with various people including: the manager, chief executive, some registered nurses, carers, eighteen residents individually, eight relatives, three volunteers and one befriender. 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 Tor Christian Nursing Home, page 8 of 44

9 What the service has done to meet any requirements we made at our last inspection The requirement The provider must review how staff serve meals in the dining room. The provider must be able to evidence to us: a) that someone is allocated to have an overview of the organisation of each meal and that they do so b) review deployment of staff during meal times to make sure there are enough staff to both serve the meal and help residents who require assistance c) review how food is transported to units from the kitchen to make sure the food is hot d) review staff competency in working in the dining room and assisting residents to eat their meals g) that staff practice is corrected immediately when problems are identified d) that staff do not assist more than one resident at the same time to eat their meal and do not leave a resident they are assisting while the resident is still eating their meal, unless it is in the resident's interest. This is in order to meet The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 4(1)(a)(b) - Welfare of users Timescale: To commence within 24 hours of this report and be completed by the 30 November What the service did to meet the requirement With the exception of element c) all other aspects of this requirement had been met. We assess this requirement as met and will address the outstanding element under Quality Theme 1, Statement 2. The requirement is: Met The requirement The Provider must make proper provision for the health, wellbeing and safety of service users by ensuring that medication management in the service is carried out in line with best practice guidance. In order to do so, the Provider must: a)ensure that staff involved in the administration of medication are aware of and fully implement the Provider's own policies and procedures; Tor Christian Nursing Home, page 9 of 44

10 b)ensure that medication is administered as prescribed; c)ensure that the administration of medication is recorded accurately; d) ensure that there are robust systems in place to accurately record and store medication which is being returned to pharmacy e)ensure that topical creams are dated when opened for use. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 4 (1)(a) - a regulation regarding the welfare of users. It is also in accordance with the National Care Standards Care Homes for Older People Standard 5 - Management and Staffing Arrangements, Standard 15 - Keeping Well Medication, the SSSC Code of Practice for Employers Sections 1.4, 2.2 and 3.2, the SSSC Code of Practice for Social Service Workers Section 6.1 Timescale for implementation: To commence within 24 hours of receipt of this report and be completed by the 30 November What the service did to meet the requirement With the exception of element e) all other aspects of this requirement had been met. We assess this requirement as met. We will address the outstanding element under Quality Theme 1, Statement 3. The requirement is: Met Inspection report continued The requirement The Provider must ensure that all staff who complete observation charts such as daily fluid intake and food diaries, do so consistently and accurately. In order to achieve this, the manager must ensure that staff who carry out such observations are trained in the use of the service's charts including how to evaluate the content of these and plan care accordingly. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 4(1)(a) - Welfare of users and Regulation 15(b)(i) - staffing. The National Care Standards, Care Homes for Older People, Standard 5 - Management and staffing arrangements should be taken into account when complying with this Requirement. Timescale for implementation: to commence within 24 hours of receipt of this letter and be completed by 30 November 2012 What the service did to meet the requirement We were unable to assess if this requirement had been met because residents were not on fluid balance charts. Therefore we were unable to assess how these were used. For that reason this requirement is not met. The requirement will be made again under Quality Theme 1, Statement 3, and followed up at the next inspection. The requirement is: Not Met Tor Christian Nursing Home, page 10 of 44

11 The requirement The provider must ensure that where a service user has a pressure ulcer the care plan contains the following: (viii) level of risk and skin integrity status (ix) type of mattress (or if none in use) in use (with settings) (x) type of chair cushion in use (or if none in use) (xi) frequency of skin checks (xii) frequency of positional changes or if a turning chart was in use (xiii) any other relevant individual care intervention and (xiv) the frequency of the risk assessment and care plan review. This is to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011(SSI 2011/210) Regulation 4(1)(a) Welfare of users. In making this requirement National Care Standards Care Homes for Older People Standard 5.1, 5.2, 5.4 Management and staffing arrangements, have been taken into account. Timescale: By 30 November 2012 Inspection report continued What the service did to meet the requirement We acknowledge that progress had been made in developing the quality of the care plans. However the care plan content varied too much, with some care plans containing all the elements of this requirement to others which contained few elements. For this reason we assess that this requirement had not been met. This is discussed under Quality Theme 1, Statement 3. The requirement is: Not Met The requirement The provider must ensure that service user care files reflect the current and changing needs of service users. In order to achieve this, the provider must: a) ensure that health care information in care plans is detailed and specific to the current needs of the individual resident b) ensure that care plans are effectively evaluated to make sure that they are meeting the aims or goals set out in the plan b) ensure that care plans are reviewed and updated as the individual resident's circumstances or condition changes Tor Christian Nursing Home, page 11 of 44

12 This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 4(1)(a) - a regulation regarding the welfare of users, and Regulation 5 - regulations regarding personal plans. Timescale: To commence on the date of receipt of this report and for completion by 30 December What the service did to meet the requirement While we acknowledge improvement in the quality of care plans, the requirement had not been met. This is discussed under Quality Theme 1, Statement 3. The requirement is: Not Met The requirement The provider must make sure that residents' health, welfare and safety are protected at all times. In order to do so the manager must a) review the current systems of staff supervision of resident lounges while residents are using these. b) make sure that systems are in place to allow all residents to easily summon staff assistance while in the lounge This is to comply with: SSI 210/2011 Regulation 4 (1) (a) - Welfare of users, Timescale:To commence within 24 hours of receipt of this report for completion by the 30 December 2012 What the service did to meet the requirement This requirement had been partially met. This is discussed under Quality Theme 2, Statement 2. The requirement is: Not Met The requirement The Provider must ensure that at all times that there are enough staff working in the service in such numbers as are appropriate for the health, welfare and safety of service users. In order to do so the Manager must ensure that account is taken of the layout of the building and any additional tasks which staff complete, when carrying out the assessment. Tor Christian Nursing Home, page 12 of 44

13 This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 4 (1) (a) - Welfare of users, Regulation 15 (a)- Staffing. Timescales: to commence within 24 hours of this report and to be in use from the 30 December What the service did to meet the requirement This requirement had been partially met. This is discussed under Quality Theme 2, Statement 2. The requirement is: Not Met Inspection report continued The requirement The provider must make sure that records of the appropriate checks on the maintenance of equipment such as but not limited to call bells, bed rails is kept to confirm the ongoing safety of such equipment. This is to comply with: The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 4 (1) (a) - Welfare of users, Timescales: to commence within 48 hours of receipt of this report and be completed by the 30 November 2012 What the service did to meet the requirement This requirement had been met. The requirement is: Met Tor Christian Nursing Home, page 13 of 44

14 The requirement The Provider must ensure the health, welfare and safety of service users and provide the service in a manner which respects the independence of service users and affords them choice in the way the service is provided to them. In order to do so, the Provider must review the storage of equipment in the service, to ensure that it is stored safely, and in a way which does not restrict the choice of residents. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 3 - a regulation regarding principles, and Reg 4(1)(a) - a regulation regarding the health, welfare and safety of users. It is also in accordance with the National Care Standards Care Homes for Older People Standard Management and Staffing Arrangements, standard 8 - Making Choices, Standard 4 - Your Environment, What the service did to meet the requirement This requirement had been met. The requirement is: Met Inspection report continued The requirement The provider must ensure that suitably competent staff work in the service. In order to do so the manager must be able to evidence that staff knowledge and practice have been assessed as competent for the roles they are to carry out. Staff should be able to demonstrate how their learning has influenced their work practice. This is in order to meet the The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 15- Staffing This also takes account of the National Care Standards, Care Homes for Older People, Standard 5 - Management and staffing. Timescale: 30 December 2012 What the service did to meet the requirement This requirement had been partially met. This is discussed under Quality Theme 3, Statement 3. The requirement is: Not Met What the service has done to meet any recommendations we made at our last inspection Recommendation Tor Christian Nursing Home, page 14 of 44

15 The manager should review the keyworker/named worker system to make sure that all residents are allocated a keyworker and are aware of their identity. The manager should also make sure that both staff and residents are aware of the roles and responsibilities of a keyworker. This takes account of the National Care Standards, Care Homes for Older People, Standard 7- Moving in. What the service did to implement the recommendation This had not been fully implemented. This is discussed under Quality Theme 1, Statement 2. Recommendation The manager should continue to develop the quality assurance system. This is in order to meet the National Care Standards, Care Homes for Older People, Standard 5 - Management and Staffing. What the service did to implement the recommendation This had not been fully implemented. This is discussed under Quality Theme 4, Statement 4. Tor Christian Nursing Home, page 15 of 44

16 The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. We received a fully completed self assessment document from the service provider prior to the last inspection of the home in October We did not ask for this information to be updated before this inspection Taking the views of people using the care service into account The lay assessor spent six hours at the service speaking in general conversation with residents and relatives. During the inspection the lay assessor had individual conversations with twelve residents. All residents with the exception of one were very happy with all aspects of the service and appreciated the attention and efforts of the staff. One resident who spoke with us was unhappy about the quality and variety of food. At the end of the first inspection day, with their agreement, we passed these views to the manager. The outcome of this was that by the second inspection day the manager was able to tell us how she was trying to resolve the situation to the residents satisfaction. We also spoke individually with six residents about their experience of living at the service. All were very happy with the service they received and liked living at the service. They said that staff were respectful and caring. They were confident that staff would care for them if they were ill. Due to frailty or memory problems some residents have communication difficulties. Therefore, communication in these instances was limited to interpretation of facial expression and gesture in response to general conversation. All of the residents we met looked comfortable and they were relaxed and at ease with the staff on duty. Tor Christian Nursing Home, page 16 of 44

17 Direct comments "Its nice here" "I am happy living here" "I am well looked after." "The food is very good" "If I don't like the food, I can choose an alternative" "Staff care for me well" Taking carers' views into account The lay assessor spent six hours at the service speaking in general conversation with residents and relatives. During the inspection the lay assessor had individual conversations with six relatives about their experience of living at the service. Four relatives who spoke with the lay assessor, described how well their relatives were cared for. Two of the relatives said how pleased they were that their relative's health had improved so quickly. Another two relatives told the lay assessor how well their respective relations were cared for and how the staff could "not do enough" for them. Several relatives and volunteers spoke appreciatively, and unprompted, of the caring commitment of the recently appointed manager. The lay assessor observed that all visitors were made welcome by the volunteer manning the reception desk and answering the front door. We also spoke with two relatives. One of the relatives was very happy with the all aspects of the service. Tor Christian Nursing Home, page 17 of 44

18 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: 3 - Adequate 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 As the purpose of this inspection was to focus on requirements, recommendations and areas for improvement made at the last inspection this statement was not fully examined at this visit. However we saw that the strengths identified at the last inspection were still evident. Overall, we found that the service continued to create very good opportunities for residents and relatives to influence the way the service was provided and how it developed in the future. At the last inspection we noted that some residents were less aware of the daily running of the service, for example about written agreements or if there were enough staff on duty. We saw that at meetings the provider was trying to share as much information about the service and organisation as possible, including long term strategic plans. This creates an opportunity for residents and relatives to gain more information about the service. The suggestion box, where anonymous comments/ suggestion about the service could be placed was opened twice monthly and the content discussed at meetings. The provider hoped that by doing this it would help show relatives and residents that all comments were responded to and taken seriously. Tor Christian Nursing Home, page 18 of 44

19 Areas for improvement We discussed with the manager the importance of developing the participation strategy in a way that makes sure that everyone had opportunities to have their say, including those residents who found communication more difficult. We will make a recommendation that the participation strategy continues to be developed (see recommendation 1) At the last inspection we were told the service information pack was being updated. We will monitor progress at the next inspection. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service should continue to develop the methods they use to involve residents and their relatives in decisions made about the service. The service should review the systems it uses to gather people's views to make sure that they remain effective for the current resident group. This is in accordance with the National Care Standards, Care Homes for Older People, Standard 11 - Expressing Your Views Tor Christian Nursing Home, page 19 of 44

20 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 As the purpose of this inspection was to focus on requirements, recommendations and areas for improvement made at the last inspection this statement was not fully examined at this visit. However we saw that the strengths identified at the last inspection were still evident. The service had met the requirement we made at the last inspection about how meals were served. We could see that there was clear overview of how meals were served and each staff member knew what task they had been allocated. Staff deployment was better and there were enough staff in the dining room to serve meals and assist residents with their meals. Staff did not help more than one resident to eat their meal at the same time and gave their full attention to the resident they were helping. The dining tables were pleasantly set with table clothes, napkins and menus and residents used the menus to consider the meal choices. A choice of drinks was offered before during and after the meal. The manager completed meals audits and if staff practice issue were identified these were addressed at the time. The lay assessor made positive comments about meal times. She noted that in the Iona dining area there was a lot of friendly chat and interaction while everybody was waiting for their meal. Residents were plied with refills of their drinks, the food was attractively presented and the tables nicely set with a printed menu at each. The staff were considerate, attentive and patient while helping some residents to eat. Staff had made considerable improvements in how they served meals. Overall meal times were much more organised and relaxed which had the potential to contribute to residents' enjoyment of their food. The provider had partially implemented the recommendation we made at the last inspection about the allocation of keyworkers. We saw that the manager had started to allocate staff as keyworkers to residents. This had not been completed because some new carers were still being inducted to the service and vacant posts were still being recruited. The outstanding aspects are discussed under the areas of development section of this statement. At the last inspection we noted that we would monitor tea times to make sure that napping residents were wakened and offered tea. We saw that all residents were offered tea when it was served. The lay assessor noted that some residents were reading copies of, or doing the Sudoku puzzles in the day's Metro. This is a free newspaper available on buses in Edinburgh. A resident explained that one of the Activity coordinators brought copies in daily and "delivered" them to interested residents. This benefits residents because these were clearly well used by them. Tor Christian Nursing Home, page 20 of 44

21 Areas for improvement While meal times had greatly improved, we still saw aspects that could be developed to make the dining experience more enjoyable for residents. For example in Sky unit we saw that over-tables which residents used to eat from when dining at easy chairs, were only set with cutlery when the registered nurse reminded carers to do so. None of the residents tried to remove the cutlery when placed before them so we were unable to establish why the tables were not set at the same time as the dining tables. The consequence of this was that all residents were not treated equally. In Sky and Iona units, we saw that residents sat at dining tables for between minutes before the meal was served. While we acknowledge the managers view that this was part of the social aspect of the meal, 30 minutes does seems a long time to sit waiting for a meal especially when we heard residents ask when the meal would be served. The manager needs to check with residents that they are happy with this arrangement. The manager agreed to monitor these aspects during meal audits and we will monitor progress at the next inspection. We still saw that there was no means of keeping food hot while transporting the food from the kitchen. While we did not see any meal served could, there is the potential that this could happen because there is no means to keep the food warm. We were told that various options were being considered. This formed part of the requirement we made at the last inspection about how staff served meals. As all other aspects of the requirement were met it is more appropriate to make a different requirement. (see requirement 1) The provider had partially implemented the recommendation we made at the last inspection about the allocation of keyworkers. This had not been completed because some new carers were still being inducted to the service and vacant posts were still being recruited. As stated in the last report, we formed the view that because of the new staff joining the team, staff would take time to become fully familiar with all residents' likes and dislikes. (see recommendation 1) There were times when the lounges, with fifteen residents using these, were unsupervised by staff and staff were not near by. This means that unless the residents were mobile and could reach the call bell independently they would be unable to call for staff help. This limits residents' choices and safety. We have discussed this in Quality Theme 2, Statement 2. Tor Christian Nursing Home, page 21 of 44

22 As previously stated in this report when staff were engaging with residents they did so in a very respectful and friendly manner. However outwith care tasks we saw limited social interaction. For example on the ground floor, we saw staff enter the sitting room and leave again without any acknowledgement to residents present. We saw one staff member on the ground floor begin to assist a resident to move from a wheelchair without first explaining what they were about to do. We saw staff bring residents in wheelchairs into the lounge and leave them in the wheelchairs until a hoist was brought to the lounge and then all residents were transferred to easy chairs. This limited the extent to which residents were treated with respect and as individuals. The lay assessor noted that in the main lounge at least 15, occasionally 20, residents were in it for most of the day. The lay assessor saw no disrespectful or rude behaviour by staff to residents but the staff in the main lounge did not seem to recognise the value of communicating with residents or the opportunities that they had for communicating while doing things for residents. The manager was firm that this was not acceptable and agreed to address this with staff. We will monitor progress at the next inspection. The lay assessor noted that the atmosphere in the main lounge was neither homely nor cheerful. This was despite it having beautiful big windows, overlooking lovely gardens and facing south into the sunshine. We also noted this. This was in contrast to Iona and Sky units, which were smaller units and this contributed to a cosier atmosphere. The provider was aware that the seating arrangements in the ground floor lounge did not enhance the atmosphere. The provider was considering options to improve this while maintaining the benefit of the spaciousness of the room. We will monitor progress at future inspections. In grading this Statement we have taken into account the impact that the areas for improvement had on the ability of residents to make individual choices in their everyday life. The grade reflects that there were strengths which had a positive impact on residents' lives but, while these areas for improvement were not having a substantially adverse effect, they were constraining staff performance and restricting residents' choice. Tor Christian Nursing Home, page 22 of 44

23 Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 1 Requirements 1. The provider must review how food is transported to units from the kitchen to make sure the food is hot. This is in order to meet The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 4(1)(a) - Welfare of users Timescale: To commence within 24 hours of this report and be completed by the 30 April 2013 Recommendations 1. The manager should review the keyworker/named worker system to make sure that all residents are allocated a keyworker and are aware of their identity. The manager should also make sure that both staff and residents are aware of the roles and responsibilities of a keyworker. This takes account of the National Care Standards, Care Homes for Older People, Standard 7- Moving in. Tor Christian Nursing Home, page 23 of 44

24 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths As the purpose of this inspection was to focus on requirements, recommendations and areas for improvement made at the last inspection this statement was not fully examined at this inspection. However we saw that the strengths identified at the last inspection were still evident. The provider had met the requirement we made at the last inspection about medication. We saw that all medication that was to be returned to the pharmacy was securely stored with restricted access. Registered nurses told us that they were familiar with the provider's medication policy and had received training in the management of medication. Medication Administration Recording sheets were completed to show that medication had been administered as prescribed. One aspect of the requirement was not met but we assessed that this would be more suitably addressed under a recommendation. This is discussed under the areas of improvement section of this report. Six monthly reviews of care were taking place which created an opportunity for residents to say if the care was provided in the way they wanted. A system was in place to show the prevalence of pressure ulcers and was updated monthly. As a result staff had an overview of how healthy residents skin was. Individual case tracking and discussion with staff, residents and relatives showed us there was regular contact with a range of healthcare professionals including general practitioner, dentists and opticians. We saw examples of other healthcare professionals being contacted for expert guidance and staff following the guidance given to make sure residents' healthcare needs were met. Residents told us they felt that staff looked after them well. We visited a resident who was poorly on the inspection day but looked very well cared for and comfortable. They told us that staff looked after them well. Relatives who spoke with us were mainly positive about the care provided. When in our presence staff were seen to be polite, kindly and patient in their approach to residents. Staff who spoke with us could explain residents' health care needs and could tell us how they provided this. We concluded that staff knew residents' health care needs and this would benefit residents. Tor Christian Nursing Home, page 24 of 44

25 Areas for improvement With permission we checked residents' bedrooms to make sure these were comfortable and clean. We found dirty hairbrushes and toothbrushes. This limited the extent to which residents were treated with respect and their health needs cared for. This is discussed under Quality Theme 2, Statement 2. We also found that residents' topical creams were not dated when opened for use. This is important to know because it helps with stock control and helps staff to judge when to order more cream. It also helps staff to make a judgement about whether cream needs to be replaced if in use for a long time. The manager told us that she would add the checking of creams held in residents' bedrooms to the medication audit. (see recommendation 1) We made a requirement at the last inspection about the completion of charts such as fluid balance charts which are used to record how much fluid a resident drinks each day. We were unable to assess if this requirement had been met because no resident was at risk of dehydration and therefore was not on a fluid chart. We will make the requirement again and assess progress at the next inspection. (see requirement 1) The service had not met the requirement made at the last inspection about the content of care plans for pressure ulcer care. We still saw discrepancies in the quality of care plans because these did not consistently document pressure ulcer information. This limits the extent to which consistent pressure ulcer care would be given to residents. This was despite staff receiving intense training and support. Examples of care plan discrepancies were shown to the manager. We acknowledge that pressure ulcers were healing but information was not easy to find. (see requirement 2) Since the last inspection the service had introduced TMARs to record the application of topical cream to residents' skin. We examined a sample of these and saw these were not consistently or accurately completed. Examples of this were shown to the manager. The consequences of this is that we are unable to establish if residents cream is being applied as prescribed by the GP to protect their skin. (see requirement 3) Tor Christian Nursing Home, page 25 of 44

26 The service had not met the requirement made following the last inspection about care plans. While we acknowledge that the quality of the care plans had improved because these were more person centred in content, these still did not give enough specific direction about how staff were to provide the care. The care plans were not always updated with information from other health care professions or after incidents or accidents. The evaluation of care plans did not always show that staff were considering if they were helping residents to achieve their goals, or if there was more that could be done to help them to do this. We looked at charts that staff used to record and monitor some aspects of residents' care, such as the application of topical creams charts. We did not find evidence that staff evaluated the information the charts provided to see if any changes were needed to the way staff gave care. (see requirement 4) We observed that a resident sat in a wheelchair for the whole day, which was their choice. However the resident's care plan and risk assessment took no account of this or the potential effect on the resident's skin. (see requirement 4) In grading this Statement we have taken into account the impact that the areas for improvement had on the ability of residents to make individual choices in their everyday life. The grade reflects that there were strengths which had a positive impact on residents' lives but, while these areas for improvement were not having a substantially adverse effect, they were constraining staff performance and restricting residents' choice. Grade awarded for this statement: 3 - Adequate Number of requirements: 4 Number of recommendations: 1 Requirements 1. The Provider must ensure that all staff who complete observation charts such as daily fluid intake and food diaries, do so consistently and accurately. In order to achieve this, the manager must ensure that staff who carry out such observations are trained in the use of the service's charts including how to evaluate the content of these and plan care accordingly. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) Regulation 4(1)(a) - Welfare of users and Regulation 15(b)(i) - staffing. The National Care Standards, Care Homes for Older People, Standard 5 - Management and staffing arrangements should be taken into account when complying with this Requirement. Timescale for implementation: to commence within 24 hours of receipt of this letter and be completed by 30 March 2013 Tor Christian Nursing Home, page 26 of 44

27 2. The provider must ensure that where a service user has a pressure ulcer the care plan contains the following: (a) level of risk and skin integrity status (b) type of mattress in use and settings or if no mattress in use (c) type of chair cushion in use (or if none in use) (d) frequency of skin checks (e) frequency of positional changes or if a turning chart was in use (f) any other relevant individual care intervention and (g) the frequency of the risk assessment and care plan review. This is to comply with the Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011.SSI/2011/210 Regulation 4(1)(a) Welfare of users. In making this requirement National Care Standards Care Homes for Older People, Standard 5.1, 5.2, 5.4 Management and staffing arrangements, have been taken into account. Timescale for implementation: to commence within 24 hours of receipt of this letter and be completed by 30 March The Provider must ensure that staff who complete treatment plans for topical creams do so consistently and accurately. The content of treatment plans must be evaluated and care planned accordingly. This is in order to comply with SSI 2011/210 Regulation 4(1)(a) - Welfare of. The National Care Standards, Care Homes for Older People, Standard 5 - Management and staffing arrangements should be taken into account when complying with this Requirement. Timescale for implementation: to commence within 24 hours of receipt of this letter and be completed by 30 March 2013 Tor Christian Nursing Home, page 27 of 44

28 4. The provider must ensure that service user care files reflect current and changing needs of service users. In order to achieve this, the provider must: a) ensure that health care information in care plans is detailed and specific to the current needs of the individual resident b) ensure that care plans are effectively evaluated to make sure that they are meeting the aims or goals set out in the plan b) ensure that care plans are reviewed and updated as the individual resident's circumstances or condition changes e) ensure that care plans and risk assessments take account of the effects of a residents choice to sit for long periods in a wheelchair This is in order to comply with SSI 210/2011 Regulation 4(1)(a) - a regulation regarding the welfare of users, and Regulation 5 - regulations regarding personal plans. Timescale: To commence on the date of receipt of this report and for completion by 30 June Recommendations Inspection report continued 1. It is recommended that the manager ensures that staff date residents' topical creams when opened for use. This takes account of the National Care Standards, Care Homes for Older People, Standard 15 - Keeping well - medication Tor Christian Nursing Home, page 28 of 44

29 Quality Theme 2: Quality of Environment Grade awarded for this theme: 4 - Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths We saw that the strengths and comments made in Quality Theme 1 Statement 1 also apply to this statement. As a result of residents comments Wi-Fi and Skype were available in residents bedrooms and lounges. This created an opportunity for residents to keep in touch with family and friends. We concluded that the provider was responding to residents comments about the environment. Areas for improvement We have made a recommendation about this at Quality Theme 1, Statement 1. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Tor Christian Nursing Home, page 29 of 44

30 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths As the purpose of this inspection was to focus on requirements, recommendations and areas for improvement made at the last inspection this statement was not fully examined at this visit. However we saw that the strengths identified at the last inspection were still evident. The provider had partially met the requirement we made at the last inspection about the supervision of lounges while residents used these. We saw that Registered Nurses now allocated responsibility for the supervision of lounges for each shift. As a result all staff on duty knew which staff member was responsible for making sure residents were not left unsupervised. Other elements of this requirement were not met and are discussed under the areas of improvement section of this report. The provider had partially met the requirement we made at the last inspection about making sure there were enough staff on duty to meet residents care needs. At this inspection we saw that a dependency assessment tool was used on a monthly basis to determine the dependency of each resident. This identified the total staff hours that would be needed each day to meet the direct care for residents. Other elements of this requirement were not met and are discussed under the areas of improvement section of this report. As noted at the last inspection because of the layout of the building, we thought it would benefit from more signs to help guide residents and visitors around the different parts of the building. Since then the chief executive had received the report she had commissioned about the most suitable signage to use and was currently exploring the available options. In the meantime we saw that some residents' bedrooms had a signifier of personal importance to help them recognise their bedroom door, for example a photograph. Since the last inspection the programme of redecoration continued and residents told us that the environment was very pleasant. The lay assessor noted that the building was clean and bright and the modern parts had spacious corridors and attractively laid out and furnished lounges/dining areas. The seating in all public areas was of a very good standard especially the armchairs. Tor Christian Nursing Home, page 30 of 44