Eastercroft House Nursing Home Care Home Service Adults Airdrie Road Caldercruix Airdrie ML6 8NY Telephone:

Transcription

1 Eastercroft House Nursing Home Care Home Service Adults Airdrie Road Caldercruix Airdrie ML6 8NY Telephone: Inspected by: Alison Iles Arlene Wood Morag McHaffie Type of inspection: Unannounced Inspection completed on: 16 September 2011

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 6 3 The inspection 14 4 Other information 26 5 Summary of grades 27 6 Inspection and grading history 27 Service provided by: Eastercroft House Limited Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Alison Iles Telephone enquiries@scswis.com Eastercroft House Nursing Home, page 2 of 29

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 N/A Quality of Environment 3 Adequate Quality of Staffing 3 Adequate Quality of Management and Leadership N/A What the service does well The service is ensuring that where any changes are being made whether to the environment or documentation that the relevant people, including residents and staff are being involved in this process. Any changes being made are being achieved in a planned way to ensure that people understand what is being done, why and what the outcome will be for the service and those who live and work there. What the service could do better The service need to ensure that they follow their own recruitment procedures to ensure that when they recruit new staff they undertake all relevant checks prior to employment. The service also needs to review the accommodation to ensure that where possible attempts are made to make the environment as homely as possible. Residents should continue to be involved in this process. What the service has done since the last inspection The service had continued to address requirements and recommendations made at the last inspection. The result of this was that the majority of these had been either fully or partially met. This included further development of personal care plans, Eastercroft House Nursing Home, page 3 of 29

4 ensuring plans were reviewed at least once every six months, improvement in the recording of and investigation of internal complaints and the introduction of a development plan for the service. Conclusion The service had continued to take actions to address issues previously highlighted to them. They had started to introduce action plans to show how they would develop the service over the coming year taking in to account the four Quality Themes inspected by us. This should help to ensure that the service continues to move forward even if there are changes in key personnel. Who did this inspection Alison Iles Arlene Wood Morag McHaffie Eastercroft House Nursing Home, page 4 of 29

5 1 About the service we inspected Before 1 April 2011 this service was registered with the Care Commission. On this date the new scrutiny body, Social Care and Social Work Improvement Scotland (SCSWIS), took over the work of the Care Commission, including the registration of care services. This means that from 1 April 2011 this service continued its registration under the new body, SCSWIS. The history of grades that the service was previously awarded by the Care Commission are also available on the SCSWIS website. Eastercroft House is a privately owned care home set in extensive grounds close to the village of Caldercruix in North Lanarkshire. The home operates from two buildings and provides care and support for up to 80 adults with mental health issues. There were 78 service users at the time of the inspection. At the time of the inspection the service was in the process of appointing a new manager, the previous manager having left in July The homes aim is to provide support to service users in a manner which maximises their independent functioning and preserves dignity, self respect and confidence. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - N/A Quality of Environment - Grade Quality of Staffing - Grade Quality of Management and Leadership - N/A 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. Eastercroft House Nursing Home, page 5 of 29

6 2 How we inspected this service The level of inspection we carried out In this service we carried out a high intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection In this service we carried out a high intensity inspection. We carry out these inspections when we have assessed the service may need a more intense inspection. We compiled this report following an unannounced inspection. The inspection was carried out by SCSWIS inspectors Alison Iles, Morag McHaffie and Arlene Woods. The unannounced inspection took place on the 7 September 2011 between12 noon and 7.15pm and 8 September 2011 between 9am and 4pm. Feedback was provided on the 16 September The service completed a self assessment form prior to the inspection and information from this was considered at the inspection. In this inspection we gathered evidence form various sources, including the relevant sections of policies, procedures, records and other documents including: * observing how staff work * personal plans of people who use the service * training records * health and safety records * meeting minutes for those who use the service and staff * accident and incident records * complaints records * discussions with various people, including: - nursing staff - care staff - the people who use the service * examining equipment and the environment (for example, is the service clean, is it set out well, is it easy to access by people who use wheelchairs?). 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 Eastercroft House Nursing Home, page 6 of 29

7 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 Eastercroft House Nursing Home, page 7 of 29

8 What the service has done to meet any requirements we made at our last inspection The requirement The provider must develop the assessment procedures for each service user to allow the development of full and relevant personal plans. This is in order to comply with SSI 114/2002. Regulation5 - Personal plans Timescale for implementation: Two months What the service did to meet the requirement The service had taken sufficient action to address this requirement. The requirement is: Met The requirement The Provider must ensure that the services own policies and procedures in relation to how complaints will be dealt with is followed by all staff. 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 18 (3) and (4) - a requirement that the provider must ensure that any complaint made under the complaints procedure is fully investigated and that the Provider must, within 20 working days after the date on which the complaint is made, or such shorter period as may be reasonable in the circumstances, inform the complainant of the action (if any) that is to be taken. Timescale for implementation: 24 hours of receipt of this report. What the service did to meet the requirement The service were able to demonstrate that they were following their own policies and procedures in relation to managing complaints The requirement is: Met Eastercroft House Nursing Home, page 8 of 29

9 The requirement The provider must ensure that all staff have the appropriate training in food hygiene to allow them to facilitate service user cooking skills groups. 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 15(b)(i) - a requirement that the Provider ensures that persons employed in the provision of the care service receive training appropriate to the work they are to perform. Timescale for implementation: one month from receipt of this report What the service did to meet the requirement Staff have had updated food hygiene training. This is being provided to all staff working in the home. The requirement is: Met Inspection report continued The requirement The provider must ensure that all service users personal plans are fully reviewed at least once in every 6 months. 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 5(b)(iii) - Review of personal plans. Timescale for implementation: 3 months from receipt of this report What the service did to meet the requirement New systems have been introduced to ensure that reviews are carried out within set timescales. The requirement is: Met Eastercroft House Nursing Home, page 9 of 29

10 The requirement The provider must ensure that a training plan is in place that provides staff with the necessary skills to address service user's care and support needs. 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 15(b)(i) - a requirement that the Provider ensures that persons employed in the provision of the care service receive training appropriate to the work they are to perform. Timescale for implementation: 3 months from receipt of this report What the service did to meet the requirement The service were currently developing a training plan. This will be added to as a result of individual staff supervision sessions. The requirement will remain until the training programme is fully developed and will be followed up at the next inspection. The requirement is: Not Met Inspection report continued The requirement The provider must ensure that the manager of the service undertakes a relevant management qualification to ensure that they have the skills and knowledge to allow them to effectively manage the service. The Provider must notify us when the manager commences this course. 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 15(b)(i) - a requirement that the Provider ensures that persons employed in the provision of the care service receive training appropriate to the work they are to perform. Timescale for implementation: 12 months from receipt of this report What the service did to meet the requirement The manager in place at the last inspection was no longer in post and the service were actively recruiting a new manager. There is a commitment to providing access to a relevant management qualification to the new manager, if they do not come with this qualification, and also looking at providing this to other senior staff in the home. We will follow this up at the next inspection. The requirement is: Not Met The requirement A comprehensive and overarching development plan must be developed for the service with clear action plans, priorities, identified responsibilities and timescales for action. 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 Principles - a requirement that a Provider of a care service shall provide the service Eastercroft House Nursing Home, page 10 of 29

11 in a manner which promotes quality and safety and respects the independence of service users and affords them choice in the way the service is provided to them. Timescale for implementation: Two months from receipt of this report What the service did to meet the requirement The service were able to show that they had started to address this requirement but work was ongoing. We will review this at the next inspection. The requirement is: Not Met Inspection report continued The requirement The provider must ensure that the process of supervision is developed to allow staff to fully understand its role and function. The process must be used to identify and give assistance to staff in gaining access to the training required appropriate to their role within the service. 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 9 Fitness of employees and Regulation 15 Staffing Timescale for implementation: Three months from receipt of this report What the service did to meet the requirement Training on supervision was ongoing at the time of the inspection. This was to explain to all staff the purpose and format of supervision prior to it being introduced. Once introduced the service will be able to identify gaps in individual staff training and knowledge and plan training around this information The requirement is: Not Met The requirement The service must submit an annual return as and when requested by us. This is in order to comply with Public Services Reform (Scotland) Act 2010 Section 53(6) which states SCSWIS may at any time require a person providing any social service to supply it with any information relating to the service which it considers necessary or expedient to have for the purposes of its functions under this Part. What the service did to meet the requirement The service will be unable to address this requirement until they are asked by us to submit a new annual return in January 2012 The requirement is: Not Met Eastercroft House Nursing Home, page 11 of 29

12 What the service has done to meet any recommendations we made at our last inspection 1. The service should develop a system of action planning and feedback from meetings and suggestions made. Sufficient action had been taken by the service to address this recommendation. They had developed a uniform system for all meetings where by there is an agenda, minute, action plan with timescales and personnel actioned to carry points through to conclusion. 2. The participation policy should be further developed to give service users and carers information about he methods of involvement, timescales of surveys etc and methods of feedback used. The service had still to address this recommendation. We will follow this up at the next inspection. 3. The service should ensure that appropriate arrangements are i8n place for booking of mini bus or alternative arrangements made to ensure planned activities take place. Arrangements have been put in place to address this recommendation. The service has also increased the pool of transport as a way of resolving this issue. 4. The accident incident policy should be further developed to give clearer information about individuals wishes of service users and their carers as to when and in what circumstances they want to be contacted following and accident or incident. Action has been taken to address this recommendation and new procedures are in place and followed. 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: No 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. We were satisfied with the way the service provider had completed this and with the Eastercroft House Nursing Home, page 12 of 29

13 relevant information they had given us for each of headings that we grade them under. The service provider identified what they thought they did well, some areas for development and any changes they had planned. Taking the views of people using the care service into account Those spoken with during the inspection were able to comment on their views of living in Eastercroft. Most spoke positively about opportunities and outings that were made available to them and there was evidence that individuals likes and dislikes were being taken into account when planning activities and menus. Those who worked in the garden indicated that they enjoyed growing vegetables and liked the idea that their produce was used in the homes kitchen. A number of residents indicated that they did not wish to stay in Eastercroft mainly due to the distance the service was from their homes and families. Peoples views on the service were variable but for many this was due to their short term memory impairments and related health issues. Taking carers' views into account No relatives were spoken with as part of this inspection. Eastercroft House Nursing Home, page 13 of 29

14 We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. 3 The inspection Quality Theme 1: Quality of Care and Support - NOT ASSESSED Eastercroft House Nursing Home, page 14 of 29

15 Quality Theme 2: Quality of Environment Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths Taking into account the evidence presented and discussions with service users and staff, the service were performing at a good standard in relation to this Quality Statement. The service was able to show that they were asking people who live in the service about any changes to the accommodation. Recent examples included the naming of the four units in the building known as E2, choosing seating for the cinema room and involvement in the redevelopment of the hairdressers room. Areas for improvement Within the self assessment, completed by the service prior to this inspection, the service had identified the following areas where they would like to make improvements. * To develop a service users forum to look at the ongoing development of the environment * To consult with residents re best use of communal space. The outcome of these discussions and will be followed up at future inspections. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths Taking into account the evidence presented and discussions with service users and staff, the service was found to be performing at a good standard in relation to this Quality Statement. All residents or their relatives were issued with a residency agreement when they are admitted to the service. This clearly outlined the terms and conditions of an individuals stay in the service. Information relating to the services insurance policy Eastercroft House Nursing Home, page 15 of 29

16 was provided in the welcome pack. Appropriate risk assessments were carried out both in relation to the accommodation and where needed for individual residents. Accountable recruitment procedures were in place for the appointment of staff and volunteers. Staff rotas indicate that the service was appropriately staffed for the number of service users accommodated. A complaints procedure was available and there was evidence that this was being used regularly by residents. Where complaints were made these were being followed through in line with the services own procedure. This addresses a requirement made at the last inspection. A range of audits were being carried out on the accommodation on a monthly basis this included physical checks on the accommodation, kitchen cleanliness and maintenance of bedrooms. They also audited accident and incident records and where possible action was taken to reduce the risk of these recurring. There were a range of polices and procedures in place to ensure that the environment was safe and residents protected. Good infection control practices were observed to be in place. The service have a number of staff who have completed a course to become 'Cleanliness Champions'. The course covered areas such as infection control and hand hygiene. All residents had access to an emergency call system in their bedroom and lounge areas. Accidents and incidents were being regularly audited. Where action was needed to reduce the likelihood of these reoccurring this was being clearly documented. Maintenance contracts were in place for equipment such as hoists and records showed that regular checks were being carried out on this equipment. The service had their own handyman this ensured that any repairs needing carried out were done so quickly. There was evidence that where other agencies such as Environmental Services had visited and required action to be taken this was done. Areas for improvement The service had identified the need to review the ventilation to the smoke rooms as this was currently not sufficient to ensure that smoke did not drift in to other areas of the building. At the time of the inspection the Provider was fitting a new ventilation system to one room to check if this would help to resolve the problem. The service were also aware if the need to ensure that smoke room doors were always closed and planned to take action to address this. At the time of providing feedback to the Eastercroft House Nursing Home, page 16 of 29

17 provider action had already been taken to remove the door guards from these doors so that they could not be held open. There was a recognition that work would also need to be carried out with residents to ensure that they were aware of the smoking legislation, impacts this had on the service and the need to comply with this. The service were failing to notify us about all significant accidents or incidents such as when people required medical treatment as a result of these. (See requirement 1) As an area for improvement the service should ensure that all maintenance records are completed in pen and that records are appropriately dated. The service need to ensure that where residents have equipment such as kettles in their rooms that appropriate risk assessments have been carried out to ensure that where possible action has been taken to reduce the likely hood of and accident occurring. Although residents in E2 had access to a secure garden area the provider has been asked to consider creating an additional secure garden space for residents who may require this who live in E1. Grade awarded for this statement: 4 - Good Number of requirements: 1 Number of recommendations: 0 Requirements 1. The service must notify the Care Inspectorate of any significant incidents or accidents. This is in order to comply with SSI/2002/114 Regulation 21 (2)(b)(c) - a requirement that a provider of a care home service shall give notice to the Inspectorate without delay of the occurrence of any serious injury to a service user; any theft of accident. Timescale for implementation: 24 hours from receipt of this report. Statement 3 The environment allows service users to have as positive a quality of life as possible. Service strengths Inspection report continued Taking into account the evidence presented and discussions with service users and staff, the service was found to be performing at an adequate standard in relation to this Quality Statement. Eastercroft is an 80 bedded care home situated in the Caldercruix area outside Airdrie. The accommodation is spread over two buildings E1 which can accommodate 48 people, three rooms for double occupancy, and E2 which has 32 single ensuite Eastercroft House Nursing Home, page 17 of 29

18 bedrooms. A number of residents in E1 have access to ensuite facilities however a range of shared bathrooms and shower facilities were also available. At the time of the inspection there was evidence that the service were reviewing the use of the accommodation to create additional facilities for residents including a wet floor shower room and possibly additional bed-sits which would be equipped to allow people to develop skills to assist them to move back in to the community. Residents and their families are encouraged to personalise and decorate their bedrooms. A number of bedrooms seen had been personalised by residents over time. Since the last inspection residents had chosen names for the units in E2 to give the different wings a sense of identity. Some of the units had also been pained in a different colour to help with identification. An emergency call system was fitted to bedrooms. A range of communal areas were available, including a designated smoking areas. Security at the front entrances was effective and a passenger lift was available between floors. A family room was available that allowed relatives and residents to meet in private if they do not wish to use their bedrooms. Residents had access to an assessment kitchen and there was evidence of this being used by people to prepare their favourite meal as well as carrying out their own laundry. Residents had access to large garden area some of which was secure. Here residents grow their own fruit and vegetables, which were used by the kitchen. Those responsible for the growing these spoke positively about their achievements and advised that they enjoyed being out in the fresh air and being able to do something constructive with their time. Raised beds had also been created for those residents in wheelchairs. Some residents were also responsible for looking after the chickens and collecting the eggs. Information for residents and carers was displayed in main notice boards throughout the service. This included information on weekly planned events that took place both in and out with the service. Residents were also supported on a weekly basis to develop their own activity programme and were encouraged by staff to take part in all that was being offered. The service continues to encourage and support residents to access local shops and facilities. Eastercroft House Nursing Home, page 18 of 29

19 Areas for improvement Within the self assessment submitted to us prior to the inspection the following areas for improvement were identified by the service: * Reinforce the use of the rehabilitation kitchen for all residents * Further development of personal plans to include individual programmes for independent life skills * Further adaptation to the garden to make it more accessible to all * Enhance the living environment to make it more homely involving residents in this process * Reviewing the lay out of the home with residents involvement We would agree that these are the areas that the service have to work on to help to improve there grading in this Quality Statement. In addition the service should also review the current practice of locking residents out of dining areas other than at meal times. This is to ensure that residents have access to all areas of the home unless there is an assessed and regularly reviewed risk assessment as to why doors remain locked. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Inspection report continued Eastercroft House Nursing Home, page 19 of 29

20 Quality Theme 3: Quality of Staffing Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service strengths Taking into account the evidence presented and discussions with service users and staff, the service was found to be performing at a good standard in relation to this Quality Statement. There was some evidence that the service sought the views of residents about new staff employed in the service. Residents are encouraged to be involved in either staff interviews or in meeting potential staff informally. The views of residents are recorded and taken in to account when employing new staff. Areas for improvement Within the self assessment submitted to us prior to the inspection the following areas for improvement were identified by the service: * Developing a committee involving residents to look at developing: pre interview meetings with prospective staff; a person spec detailing qualities residents would expect from staff and set questions to be asked at interviews * Developing the review process to give more dedicated approach to resident feedback about staff and management. As an area for development the service need to consider and develop a range of ways in which residents and relatives can make comment on staff from recruitment and throughout their employment in the service. The service must also be able to show how they have acted on comments made. (See recommendation 1). Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service need to develop ways in which residents and their relatives can participate in assessing and improving the quality of staff from recruitment to on going performance. National Care Standards Care Homes for People with mental health problems: Standard 5 Management and Staffing and Standard 11 Expressing Your Views. Eastercroft House Nursing Home, page 20 of 29

21 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 Taking into account the evidence presented and discussions with service users and staff, the service was found to be performing at an adequate standard in relation to this Quality Statement. The service had polices in place regarding the recruitment of staff. Staff files examined, at the inspection, held relevant recruitment information on staff including application forms, references and Disclosure Scotland checks. Staff were initially employed on a probationary period. At the end of this time an appraisal would take place to ensure that the member of staff was suitable to remain in employment. An induction programme was in place for all new staff. The service had a policy in relation to staff supervision and appraisals. A supervision training programme was currently being rolled out to all staff. Staff spoken with, who had attended this training, advised that the training had provided an overview of what supervision was about and this had been helpful. Following this training individual staff training dates would be arranged. We will follow up how effective this has been at the next inspection. Care staff were aware of the Scottish Social Services Council (SSSC) and had been provided with copies of the SSSC codes of Conduct of Practice. They were aware of the need to register with this body in the coming years. The service had policies in relation to adult and child protection. Staff training in relation to these areas had been taking place and was ongoing. Staff spoken with indicated that as long as all staff were on duty then the current staffing levels were sufficient to meet the needs of the residents. Staffing levels had been increased in the morning to reflect the needs of the residents. Areas for improvement Inspection report continued The service had identified the following areas for improvement in the self assessment submitted to us. * New induction programme to be introduced * Supervision training for all staff As stated above the training in relation to supervision had started with dates planned throughout September to ensure all staff received the training. We would agree that the induction content needs to be reviewed to reflect the Eastercroft House Nursing Home, page 21 of 29

22 mandatory training needed to work in the service. We will re-look at this at the next inspection. From discussions with new staff and staff recruitment files there was evidence that the service was not always following best practice when it came to recruiting staff. This included relevant police checks not being returned prior to employment and the most relevant and up-to-date references being asked for. There was evidence of staff commencing employment prior to police checks being requested. The service did state that staff employed with out these checks would be supervised at all times until these checks came through. This was not evidenced in practice. The service were therefore not following there recruitment practice in ensuring that people were safe to be employed in the service prior to them starting work (see requirement 1). Although the service had a recruitment policy and procedure in place these should be reviewed to ensure that they fully reflect best practice guidance in terms of safe recruitment (see recommendation 1). The service was not currently operating to the staffing schedule issued by us. They had however adjusted the staffing levels to meet the needs of those living in the home. The service should submit a variation to the registration in order to adjust the staffing schedule to reflect the current staffing in place. Grade awarded for this statement: Number of requirements: 1 Number of recommendations: 1 Requirements 1. The provider must be able to demonstrate that when staff are recruited that all necessary checks have been carried out and results obtained prior to them commencing employment. This must include any staff being reemployed by the service. This is in order to comply with SSI 2011/210 Regulation 9 - Fitness of employees Timescale for implementation: 1 week from receipt of this report. Recommendations 1. The service should review and update there recruitment policy and procedures to reflect Best Practice Guidance. National Care Standards Care Homes for people with mental health problems: Standard 5 Management and Staffing. Statement 3 Inspection report continued We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Eastercroft House Nursing Home, page 22 of 29

23 Service strengths Taking into account the evidence presented and discussions with service users and staff, the service was found to be performing at an adequate standard in relation to this Quality Statement. The service were starting to look at the training made available to staff and hoped to build on this when staff supervisions had been carried out and individuals training needs highlighted. Staff spoken with advised that they had had regular training opportunities over the past few months and have access to training opportunities as they come in to the service. Staff stated that if they felt that they needed training in any areas they could approach the management of the service and this would be sourced. There was evidence that the service were starting to also look at the particular care and support needs of the resident group and organising training around this. A number of staff had or were identified as needing to undertake Scottish Vocational Qualification in care. New training records had recently been put in to place for staff. A training matrix had also been developed that showed training undertaken by staff. This could be used to clearly indicate when training needed to be updated and allows the service to have an overview of all training completed. As previously stated a number of staff employed in the service were recognised trainers in a number of areas including moving and assisting. This ensures that all staff receives this training and any updates on regular basis. There was evidence that where staff had undertake training that they were being asked to evaluate this training. The service should continue to build on this to ensure that all training sessions are evaluated. The Company had policies in relation to staff appraisals and supervision, which set out how often these should take place. Staff meetings take place on a regular basis and staff advised that they are able to discuss any issues they have about the service at this time. Staff found these meeting beneficial. Areas for improvement Inspection report continued The service had identified the following areas for improvement in the self assessment submitted to us. * New induction programme to be introduced * Employee development plans to be put in place to record all training undertaken by staff * Development of new training programme * Additional staff to start to undertake an SVQ in social care Eastercroft House Nursing Home, page 23 of 29

24 * Additional staff training needs to be identified and relevant training sourced They hoped to achieve this by the end of October In order to address the above the service were about to commence staff supervision sessions where individual training needs of staff could be identified and then relevant training planned from this. This will help to ensure that all staff had the relevant training to allow them to meet the care and support needs for those they support. There was evidence that the service are committed to providing staff with the relevant training to allow them to provide good quality care to residents. We will check how well the service has achieved the above at the next inspection. The management were currently developing an action plan from the feedback received from the staff survey issued in June The service had a range of policies and procedures that are relevant to the home. The majority of these were in need of updating to ensure that they not only reflected best practice guidance in key areas but that they were also fully reflective of how the home operated in these areas. (See recommendation 1). Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 1 Recommendations Inspection report continued 1. The service should review its policies and procedures to ensure that they reflect up-to-date best practice guidance and also personalised to the service. National Care Standards Care Homes for people with mental health problems: Standard 5 Management and Staffing Arrangements. Eastercroft House Nursing Home, page 24 of 29

25 Quality Theme 4: Quality of Management and Leadership - NOT ASSESSED Eastercroft House Nursing Home, page 25 of 29

26 4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information We looked at residents medication during this inspection. We found that the service had a good audit in place that was identifying the same issues that we came across. The service was actively trying to resolve issues identified through discussions with the pharmacy and GP. Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). Eastercroft House Nursing Home, page 26 of 29

27 5 Summary of grades Quality of Care and Support - Not Assessed Quality of Environment - Statement 1 Statement 2 Statement Good 4 - Good Quality of Staffing - Statement 1 Statement 2 Statement Good Quality of Management and Leadership - Not Assessed 6 Inspection and grading history Date Type Gradings 7 Jun 2011 Unannounced Care and support Environment Not Assessed Staffing Not Assessed Management and Leadership 2 - Weak 17 Feb 2011 Unannounced Care and support Environment Staffing Management and Leadership Not Assessed 3 Sep 2010 Announced Care and support Environment Staffing Management and Leadership Not Assessed 12 Jul 2010 Re-grade Care and support Not Assessed Environment Eastercroft House Nursing Home, page 27 of 29

28 Staffing Management and Leadership Not Assessed Not Assessed 19 Mar 2010 Unannounced Care and support 1 - Unsatisfactory Environment 2 - Weak Staffing Management and Leadership 2 - Weak 16 Sep 2009 Announced Care and support 1 - Unsatisfactory Environment 2 - Weak Staffing Not Assessed Management and Leadership Not Assessed 16 Mar 2009 Announced Care and support Environment Staffing Management and Leadership 2 - Weak 10 Nov 2008 Unannounced Care and support Environment Staffing Management and Leadership 2 - Weak 28 May 2008 Announced Care and support Environment Staffing Management and Leadership 2 - Weak All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Eastercroft House Nursing Home, page 28 of 29

29 To find out more about our inspections and inspection reports Read our leaflet 'How we inspect'. You can download it from our website or ask us to send you a copy by telephoning us on This inspection report is published by SCSWIS. You can get more copies of this report and others by downloading it from our website: or by telephoning Translations and alternative formats This inspection report is available in other languages and formats on request. Telephone: enquiries@scswis.com Web: Eastercroft House Nursing Home, page 29 of 29