Glennie House Care Home Service Adults William McComb Court Auchinleck Cumnock KA18 2HH

Transcription

1 Glennie House Care Home Service Adults William McComb Court Auchinleck Cumnock KA18 2HH Inspected by: Sandra Hobley Sean McGeechan Stephen Kennedy Type of inspection: Unannounced Inspection completed on: 19 September 2012

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 13 4 Other information 29 5 Summary of grades 30 6 Inspection and grading history 30 Service provided by: Countrywide Care Homes Limited Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Sandra Hobley Telephone enquiries@careinspectorate.com Glennie House, page 2 of 31

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 4 Good Quality of Environment 5 Very Good Quality of Staffing 4 Good Quality of Management and Leadership 4 Good What the service does well The service encouraged feedback from residents and relatives about the service that they received. The home was welcoming. Residents and relatives told us that they were happy with the quality of care within this service. What the service could do better Following this inspection the Care Inspectorate has highlighted areas for improvement which are: The provider must: Continue to review policies and procedures to ensure that they comply with Scottish Legislation and best practice guidance. Improve the robustness of the care plan audit tool. Complete social and life histories with all residents. What the service has done since the last inspection The home was clean and free from offensive odours. New care planning documentation had been fully implemented and the role of keyworker was being promoted. Medication practice had improved. Supervision training was scheduled to take place and there was improved staff Glennie House, page 3 of 31

4 communication and teamwork. Residents meetings now included discussion on more general aspects of the service including activities. Conclusion We think that this service is good. The provider had a range of quality systems and processes in place to monitor the quality of this service. The manager and staff should continue to build on the improvements made within this service. Who did this inspection Sandra Hobley Sean McGeechan Stephen Kennedy Glennie House, page 4 of 31

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 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 needs to 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 Reform (Scotland) Act 2010 and Regulations or Orders made under the Act, or a condition of registration. Where there are breaches of Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Inspectorate." Glennie House is registered to provide care to a maximum of 53 older people which may include 5 respite care places. Glennie House is a purpose built care home for older people. The service is located in the town of Auchinleck, East Ayrshire. Accommodation is provided over two floors and connected by a passenger lift. Accommodation comprises 50 single and 2 double rooms all with ensuite shower facilities. People who use the service have access to a range of communal facilities including lounge areas, dining rooms, hairdressing room, coffee area, and an enclosed garden. The service was registered with the Care Inspectorate on 31 October At the time of this inspection, 49 people were resident within the service. The service's stated aim "is to provide care for all residents to a standard of Glennie House, page 5 of 31

6 excellence which embraces fundamental principles of good care practice, which is evidenced and evaluated through the practice, conduct and control of quality within the home. Country Wide Care Homes Limited stated objective is that residents shall live in a clean, comfortable, happy and safe environment, and be treated with privacy, dignity, respect and sensitivity to their individual needs, abilities and human rights. And that staff will be responsive to the individual needs of residents and provide the optimum degree of care to ensure that the highest possible quality of life is maintained. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 4 - Good Quality of Environment - Grade 5 - Very 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. Glennie House, page 6 of 31

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 We wrote this report following an unannounced inspection that took place on the following dates: 13 September 2012 from 9.15am pm 16 September 2012 from 9.00pm pm 19 September 2012 from 9.30am am The inspection was carried out by Care Inspectorate Inspectors Sandra Hobley, Sean McGeechan and Stephen Kennedy. As requested by us, the provider sent us an annual return. The provider also sent us a self assessment form. We asked the service to distribute 35 questionnaires to people who use the service and 35 questionnaires to carers. 10 completed questionnaires were returned before the inspection from people who use the service and 10 completed questionnaires from carers. In this inspection we gathered evidence from various sources, including the relevant sections of policies, procedures, records and other documents, including: The self assessment Care files including review meeting minutes Activity records Staff communication records Complaints procedure Information about advocacy Staff training and supervision records Staff meeting records Dependency assessments Staff rotas Participation Strategy Records of service user and carer involvement Newsletters Accident /incident records Glennie House, page 7 of 31

8 Medication records Maintenance records Certificate of Registration Staffing Schedule Insurance details Quality assurance system and records including audits, monthly key performance indicators and reports We spoke to the following people: Service users (6) Manager Depute manager Quality Assurance Manager Nursing and Care Staff (4) Cook Training coordinator Laundry assistant Relatives and visitors (5) We also observed how staff work and looked at some areas of the environment. 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 Glennie House, page 8 of 31

9 What the service has done to meet any requirements we made at our last inspection The requirement Four requirements were made at the last inspection on 29 February Policies and procedures must be reviewed to ensure that they comply with Scottish Legislation and best practice guidance. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. National Care Standards Care Homes for Older People Standard 5: Management and staffing arrangements Timescale: Within 6 months of receipt of this report. What the service did to meet the requirement See quality theme 1, quality statement 1.3. The requirement is: Not Met The requirement The provider of the care service shalla) set up a system to ensure that the temperature of medication refrigerators is checked and recorded every day using a maximum and minimum thermometer and that staff know what action to take if medicines have been stored below the minimum temperature of 2 degrees C for any length of time. b) ensure that there is no ambiguity around the instruction on the prescription, medication record, dispensing label and care plan information. c) ensure that staff have adequate and accurate information to allow them to monitor resident's medication and the condition that it has been prescribed for. This might include when a medicine is started, who prescribed it, what it is for, where is has to be applied (ointment, eye drops etc), how long it has to be used for, when it should be reviewed, any tests or monitoring needed or if an accompanying behavioural chart, pain chart etc. is needed. d) ensure that there are accurate and current records of medicines [including quantity] for the use of service users which are received, carried over from a previous month, administered, refused, destroyed or transferred out of the service. e) ensure that the homes policies including medicines management procedures are updated to reflect Scottish legislation and include information about the system for ordering, checking in and disposing of medicines; how to obtain medicines out of hours and an emergency supply if stock runs out. Glennie House, page 9 of 31

10 This is in order to comply with: SSI 2011/210 Regulation 4 (1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. Timescale: Within 3 months of receipt of this report. What the service did to meet the requirement See quality theme 1, quality statement 1.3. The requirement is: Not Met Inspection report continued The requirement The provider must: a) implement new care planning documentation for all residents. b) continue to develop the content of personal plans to ensure that plans fully address the assessed healthcare needs of residents. c) improve the robustness of the care plan audit tool. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. National Care Standards Care Homes for Older People Standard 14: Keeping well - healthcare Timescale: Within 4 weeks of receipt of this report. What the service did to meet the requirement See quality theme 1, quality statement 1.3. The requirement is: Not Met The requirement The provider must ensure that the home is kept clean, hygienic and free from offensive odours. This is in order to comply with: SSI 2011/210 Regulation 4 (1)(a) - a requirement to make proper provision for the health and welfare of people. Timescale: On receipt of this report. What the service did to meet the requirement See quality theme 2, quality statement 2.1. The requirement is: Met Glennie House, page 10 of 31

11 What the service has done to meet any recommendations we made at our last inspection Ten recommendations were made at the last inspection on 29 February The service should make sure that residents clothing and personal possessions are clearly marked and properly cared for. National Care Standards Care Homes for Older People, Standard 16: Private life Findings: We continued to receive some comments about the care of residents clothing. This recommendation is continued and will be examined further at the next inspection. Progress in meeting remaining recommendations is reported within the main report under the relevant quality themes and statements. The annual return Every year all care services must complete an 'annual return' form to make sure the information we hold is up to date. We also use annual returns to decide how we will inspect the service. Annual Return Received: Yes - Electronic Comments on Self Assessment Every year all care services must complete a 'self assessment' form telling us how their service is performing. We check to make sure this assessment is accurate. The Care Inspectorate received a fully completed self assessment document from the service provider. We were satisfied with the way the service provider had completed this and with the relevant information they had given us for each heading that we grade them under. The service provider identified what they thought they did well, and some areas for development and any changes they had planned. Taking the views of people using the care service into account The Care Inspectorate supplied the home with questionnaires for distribution to people using this service. 10 questionnaires were returned. We spoke to 6 residents during our inspection. Residents told us that overall they were happy with the quality of care that they received in this home. Glennie House, page 11 of 31

12 Further comments are reported on within the report under the relevant quality themes and statements. Taking carers' views into account We refer to relatives, friends and advocates as carers. They do not include care staff. The Care Inspectorate supplied the home with questionnaires for distribution to carers. A total of 10 questionnaires were returned. We also spoke to 5 relatives during our inspection. Overall carers indicated satisfaction with the service provided. Comments included: "My relative appears to feel happy and secure in the home. All staff make an effort to speak to my relative and on every visit I have been made to feel welcome and not afraid to ask questions." "Things are improving - everywhere is looking fresher and I think the Glennie miners feature at the entrance is great. If ever I have anything to discuss I can do that." "The meals provided could be better. They are improving but tea time is not so good. A night where they had fish and chips brought in would be good...something a bit different." Further comments are reported on within the report under the relevant quality themes and statements. Glennie House, page 12 of 31

13 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: 4 - Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths The grade achieved for this quality statement at the last inspection on 29 February 2012 was 4 - Good. Elements of the evidence provided were re-visited during this inspection and this statement remains 4 - Good. We concluded this after we spoke to residents, relatives, the manager and staff. We also took into account personal plans, minutes of meetings and other supporting documentation. There was a participation policy which set out the service's commitment to involving people in the service it provides. The care service involved residents, relatives and carers and asked for their views in several ways. These included: a named nurse/key worker system, questionnaires/ surveys, review meetings, complaints/suggestions, residents and relatives meetings, access to advocacy services, and newsletters. During our inspection we also observed being used to maintain communication with families living at a distance from the care home. Residents, relatives and carers could also access the organisations website which provided information as well as a facility to leave comments. People who use the service and carers were made aware of our visit. We looked at questionnaires and minutes of meetings including a recent menu feedback survey completed by residents in August It was clear that the service took action on issues which were raised by people who use the service such as medication, loss of clothing, and the size of food portions. The home had also implemented a new menu with local suppliers for fresh vegetables and meat. The manager practised an open door policy and was accessible to residents, carers, staff and visitors to the home. Pictures and symbols were used to involve and gain the views of people with Glennie House, page 13 of 31

14 dementia, memory or other communication difficulties such as flash cards for food choices, beauty treatments and large print and picture survey forms. We made the following recommendation at our last inspection: The provider should promote and develop the role of keyworker within this service. National Care Standards Care Homes for Older people, Standard 7: Moving in National Care Standards Care Homes for Older people, Standard11: Expressing your views Findings: The photograph and name of each keyworker was displayed within individual bedrooms and people that we spoke to could tell us who this was and what the role involved. This was also discussed with staff at supervision to ensure that they understood the keyworker role. This recommendation was met. We made the following recommendation at our last inspection: The service should continue to develop the format of residents meetings. National Care Standards Care Homes for Older people, Standard 11: Expressing your views Findings: Residents meetings now included discussion on more general aspects of the service including activities. One resident told us that the advocacy service had provided support at the last meeting and that they had felt able to comment and raise issues on different aspects of the home such as food temperatures. This recommendation was met. Comments from residents and relatives included: "I am involved in a lot of decisions." "I would always speak to the manager or depute if there were any issues." "The staff make every effort to support my relative. They always communicate well with us. Staff are very supportive." Areas for improvement Inspection report continued The self assessment identified the following areas for improvement: to continue to develop the picture cards to enable residents with communication difficulties to make choices about meals in the home; and to improve attendance at residents and relatives meetings. The service should continue to develop methods for gaining feedback from people with dementia or other communication difficulties in their care and support and more general aspects of the service provided. The manager informed us that specific resources such as 'talking mats' was available in the service however we found no evidence of this being used. The manager agreed to consider training for staff to support the use of this resource. Glennie House, page 14 of 31

15 Some residents, relatives and carers told us that they were not aware of the complaints procedure for the service. This was discussed with the manager who agreed to continue to promote awareness of the homes complaints procedure. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths The grade achieved for this quality statement at the last inspection on 29 February 2012 was 3 - Adequate. Elements of the evidence provided were re-visited during this inspection and this statement regraded 4 - Good. We concluded this after we talked to residents, relatives, the manager and staff. We also took into account personal plans, minutes of meetings and other supporting documentation. Policies and procedures were being developed to guide staff and ensure that resident's health and wellbeing needs were met in accordance with Scottish Legislation and best practice guidance. Staff received training to ensure that they had the required knowledge and skills to support residents with their health and wellbeing needs. Current best practice guidance such as falls prevention and medication recording was available and being implemented within the home. Staff were encouraged to take a lead and promote areas of best practice within the home such as medication, palliative care and infection control. We found a good range of equipment throughout the home to support people's needs. Residents were supported to maintain links with their own GP and other health professionals and where this was not possible support was offered to register with a new health professional. People we consulted told us that they were confident that staff were meeting their healthcare needs, including arranging to see health professionals such as doctors, podiatrists and dentists if needed. One resident commented "my health has completely turned around." Personal plans showed that healthcare needs were assessed and an appropriate plan of care put in place to address identified needs. The clinical needs of residents were Glennie House, page 15 of 31

16 continually monitored using audit tools which were actively reviewed by the manager and areas of concern acted upon. Accidents and incidents in the home were well documented and actions put in place to minimise any identified risk. A new activities coordinator had been appointed. Monthly activity records provided good detail of activities, outings and entertainment being organised within and outwith the home. Records showed that residents were continuing to be involved in gardening, helping around the home, cleaning, baking, painting and board games. The home also had a mini bus which was well used. Some residents made their own travel arrangements. We had lunch with residents. The meal was well presented and offered a good choice. Residents told us that they were consulted about meals and menus. Comments from relatives included: Inspection report continued "I am amazed not only at the level of care that my relative receives but the way that all residents are treated. The staff always keep me up to date on changes in my relatives health including doctor's appointments, CPN appointments and medical procedures. They treat my relative with such respect and dignity. I know I can contact staff at Glennie at anytime to find out how my relative is. Staff always keep me informed and have time to explain things to me that I don't always understand." The following requirement was made at the last inspection: The provider of the care service shalla) set up a system to ensure that the temperature of medication refrigerators is checked and recorded every day using a maximum and minimum thermometer and that staff know what action to take if medicines have been stored below the minimum temperature of 2 degrees C for any length of time. b) ensure there is no ambiguity around the instruction on the prescription, medication record, dispensing label and care plan information. c) ensure that staff have adequate and accurate information to allow them to monitor resident's medication and the condition it has been prescribed for. This might include when a medicine is started, who prescribed it, what it is for, where is has to be applied (ointment, eye drops etc), how long it has to be used for, when it should be reviewed, any tests or monitoring needed or if an accompanying behavioural charts, pain chart etc. is needed d) ensure there are accurate and current records of medicines (including quantity) for the use of service users which are received, carried over form a previous month, administered, refused, destroyed or transferred out of the service. e) ensure that the homes medicines management procedures are updated to reflect Scottish legislation and include information about the system for ordering, checking in and disposing of medicines; how to obtain medicines out of hours and an Glennie House, page 16 of 31

17 emergency supply if stock runs out. This is in order to comply with: SSI 2011/210 Regulation 4 (1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. Timescale: Within 3 months of receipt of this report. Findings: Medication was administered by trained nurses. We looked at medication and storage arrangements within the home which were found to be satisfactory. The medication policy was still to be updated to reflect Scottish legislation and include information about the system for ordering, checking in and disposing of medicines; how to obtain medicines out of hours and an emergency supply if stock runs out. This requirement is met with the exception of element (e). (See requirement 1 for this quality statement) The following requirement was made at the last inspection The provider must: a) implement new care planning documentation for all residents. b) continue to develop the content of personal plans to ensure plans fully address assessed healthcare needs of residents. c) improve the robustness of the care plan audit tool. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. National Care Standards Care Homes for Older People Standard 14: Keeping well - healthcare Timescale: Within 4 weeks of receipt of this report. Findings: At the last inspection we found two different styles of care planning documentation in use which was confusing. A single format had now been introduced in all care plans and was much easier to follow. In the care plans that we sampled we were satisfied that they addressed the assessed healthcare needs of residents. We found that care plans still lacked life story information and that some information such as the medication list and contraindications did not show that this information had been reviewed or updated. The manager stated that longer term it was the intention to change the format of care plans. This requirement was met with exception of element (c) - improve the robustness of the care plan audit tool. This will enable the home to identify and address these issues. (See requirement 2 for this quality statement). The following recommendation was made at the last inspection: If the care service has concerns about services provided by GP's such as assessment of capacity, incomplete AWI Section 47 Certificates, requests for payment etc. they should consider raising these matters with the Chair of the Local Medical Committee in NHS Ayrshire and Arran. Glennie House, page 17 of 31

18 National Care Standards Care Homes for Older People Standard 14: Keeping well - healthcare Findings: A fully completed Adult With Incapacity (AWI) section 47 certificate was in place for those residents who required this. This recommendation was met. The following recommendation was made at our last inspection: A revised homely remedies policy, procedure and documentation should be developed. This needs to incorporate time limited authorisation from the prescriber about suitable medication for each individual resident. Where a resident does not have the capacity to consent to being treated with a homely remedy consent should be obtained from a welfare guardian or power of attorney. Where there is no welfare guardian or power of attorney then an appropriately completed AWI Section 47 certificate should provide the consent for staff to administer. National Care Standards Care Homes for Older People Standard 15.11: Keeping Well - Medication Findings: A revised homely remedies policy, procedure and documentation had been developed and was forwarded to the Care Inspectorate Professional Adviser - Pharmacy for comment. This recommendation was met. The following recommendation was made at our last inspection: The issue about the community pharmacy printing specific times on a MAR chart should be raised with the community pharmacy. The MAR chart is NOT a prescription sheet. It is a document used to record administration of medicines. The NHS prescription or a written "direction" from the prescriber is the authority for staff to administer medicines. Community pharmacists need to consider their practice of printing set times on MAR charts and making the decision about what time doses should be given. The pharmacy staff are unlikely to know the routine of each of the residents in the care service so it is not appropriate for them to be specifying administration times on MAR charts unless the prescriber has stated specific times on the prescription or direction. National Care Standards Care Homes for Older People Standard 15.11: Keeping Well - Medication Findings: The issue about the community pharmacy printing specific times on a Medication Administration Record (MAR) chart had been raised with the community pharmacy. The home had asked the community pharmacy to replace timings with morning, lunch etc. Currently the MAR computer software which generates the MAR chart does not allow for more than times. The community pharmacy has agreed to raise this issue with the MAR software supplier to enable letters or words to be put on the MAR. In the meantime the home have agreed to clarify in their medication policy Glennie House, page 18 of 31

19 what drug round the time equates to e.g. 9am on MAR equates to 8.30am am for morning medication. If medication is given outwith this time staff will use the back of the MAR to document time and reason for delay. This recommendation was met. Areas for improvement The following requirement was made at the last inspection: Policies and procedures must be reviewed to ensure that they comply with Scottish Legislation and best practice guidance. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. National Care Standards Care Homes for Older People Standard 5: Management and staffing arrangements Timescale: Within 6 months of receipt of this report. Policies and procedures were being reviewed and updated on a planned basis. This requirement is not fully met and will be reviewed at the next inspection. (See requirement 3 for this quality statement). The following recommendation made at the last inspection was not yet met and is continued. (See recommendation 1 for this quality statement). The service should complete individual social and life histories with all residents. National Care Standards Care Homes for Older People Standard 6: Support arrangements Grade awarded for this statement: 4 - Good Number of requirements: 3 Number of recommendations: 1 Requirements Inspection report continued 1. The provider of the care service shall - (a) ensure that the homes medicines management procedures are updated to reflect Scottish legislation and include information about the system for ordering, checking in and disposing of medicines; how to obtain medicines out of hours and an emergency supply if stock runs out. This is in order to comply with: SSI 2011/210 Regulation 4 (1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. Timescale: Within 3 months of receipt of this report. 2. The provider must: a) improve the robustness of the care plan audit tool. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. Glennie House, page 19 of 31

20 National Care Standards Care Homes for Older People Standard 14: Keeping well - healthcare Timescale: Within 4 weeks of receipt of this report. 3. Policies and procedures must be reviewed to ensure that they comply with Scottish Legislation and best practice guidance. This is in order to comply with: SSI 2011/210 Regulation 4(1)(a) - a requirement to make proper provision for the health, welfare and safety of service users. National Care Standards Care Homes for Older People Standard 5: Management and staffing arrangements Timescale: Within 6 months of receipt of this report. Recommendations Inspection report continued 1. The service should complete individual social and life histories with all residents. National Care Standards Care Homes for Older People Standard 6: Support arrangements Glennie House, page 20 of 31

21 Quality Theme 2: Quality of Environment Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths The grade achieved for this quality statement at the last inspection on 29 February 2012 was 3 - Adequate. Elements of the evidence provided were re-visited during this inspection and this statement regraded 5 - Very Good. We concluded this after we talked to residents, relatives, the manager and staff. We also took into account personal plans, minutes of meetings and other supporting documentation. See comments under Quality Statement 1.1. We visited some bedrooms which we found were personalised differently according to the wishes of the resident. Residents confirmed that they were able to visit before moving in and that they could bring in their own items of furniture. Work was ongoing to create themed areas within the home. Residents and relatives were involved in this process making suggestions and bringing in photographs and other items to help orientate residents to their rooms and general environment. Entrance and reception areas had been decorated by residents and activity staff to reflect the local link to the mining community. A lounge had been transformed into a reminiscence area and families, residents and the local community had contributed to the development of this. Another lounge had been developed to enable relatives to stay overnight to be closer to their loved one if required. Residents had also been involved in the development of the outdoor garden area. Comments from relatives included: "My relatives room is always spotlessly clean as is the rest of the home." "My relative is comfortable has a lovely room, knows everyone in the home and is well looked after. I feel that they are in good hands." "The home is nicely decorated and furnished. It is clean and friendly." The following requirement was made at the last inspection: The provider must ensure that the home is kept clean, hygienic and free from offensive odours. This is in accordance with: SSI 2011/210 Regulation 4 (1)(a) - a requirement to make proper provision for the health and welfare of people. Glennie House, page 21 of 31

22 Timescale for improvement: On receipt of this report. Findings: We found the home to be clean and fresh throughout. This requirement was met. The following recommendation was made at the last inspection: The service should review and improve the quality of accident/incident audits within the home. National Care Standards Care Homes for Older People, Standard 5: Management and staffing arrangements Findings: Accident and incident records were completed to a good standard and contained good information and detailed description of accidents and incidents. This recommendation was met. Areas for improvement The service should continue to build on good practice. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Statement 2 We make sure that the environment is safe and service users are protected. Service strengths The grade achieved for this quality statement at the last inspection on 29 February 2012 was 3 - Adequate. Elements of the evidence provided were re-visited during this inspection and this statement regraded 5 - Very Good. We concluded this after we talked to residents, carers, the manager and staff. We also took into account personal plans, minutes of meetings and other supporting documentation. There was a secure door entry system and visitors to the home were required to sign in/out. Residents and relatives told us that they were confident with the safety and security in the care home. There were policies and procedures in place to support this quality statement and staff received training to ensure that they knew how to put these into practice. Service users received a written agreement in accordance with Standard 3 of the National Care Standards care homes for older people which set out the service to be provided. A current certificate of insurance was displayed within the home. Glennie House, page 22 of 31

23 Staffing levels at the time of inspection were in accordance with the staffing schedule dated 23 March 2012 and sufficient to meet the needs of residents. Risk assessments were undertaken. Accidents and incidents were documented and audited on a regular basis to identify patterns and ensure that appropriate remedial action was taken to prevent or minimise further recurrence. A health and safety audit had been undertaken and actions arising from this audit such as the purchase of additional fire evacuation chairs and purchase of new sluice machines had been addressed. The home employed a maintenance person. There was a system of reporting repairs and records showed that these were actioned in a timely manner. Maintenance records showed that environmental and equipment checks were being regularly undertaken, and cleaning records were maintained. Areas for improvement The service should continue to build on current good practice. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Glennie House, page 23 of 31

24 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 4 - Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths The grade achieved for this quality statement at the last inspection on 29 February 2012 was 3 - Adequate. Elements of the evidence provided were re-visited during this inspection and this statement regraded 4 - Good. We concluded this after we talked to residents, relatives, the manager and staff. We also took into account personal plans, minutes of meetings and other supporting documentation. See quality statement 1.1 The views of residents and relatives were sought through the systems identified in quality statement 1.1. Some residents had been involved in the recruitment of staff or been involved in the development of interview questions. Comments from residents and relatives included: "The staff are excellent." "The entire staff at Glennie House have been so amazing in every way. My relatives care goes above and beyond anything required. The staff always take the time to inform me about my relative. The staff are friendly and knowledgeable." Areas for improvement The service should continue to develop opportunities for residents and relatives to be involved in the recruitment, induction, training and ongoing appraisal of staff. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths The grade achieved for this quality statement at the last inspection on 29 February 2012 was 3 - Adequate. Elements of the evidence provided were re-visited during this Glennie House, page 24 of 31

25 inspection and this statement regraded 4 - Good. We concluded this after we talked to residents, relatives, the manager and staff. There was a 12 week induction programme and new staff were assigned a mentor to provide additional support. There was a continuing programme of training taken place including in house e learning, external training sourced for specific needs and training delivered by in house trainers such as moving and handling and fire safety. Staff were continuing to be offered SVQ training with 77% having achieved an SVQ Level 2 or above in care. The depute manager and nursing staff were scheduled to commence management and leadership training. Staff had access to a good learning resource area within the home including access to best practice guidance. Residents and carers that we consulted were confident that staff had the knowledge and skills to care for them or their relative or friend. Comments included: "The staff are well qualified and bring their own humour and personalities." Areas for improvement The following recommendation was made at the last inspection All staff should have access to regular planned supervision. National Care Standards Care Homes for Older People, Standard 5: Management and Staffing Arrangements Findings: New supervision documentation had been introduced and supervision training had been scheduled for senior staff. It was planned to increase the number of staff trained to carry out supervision to enable all staff to have access to regular planned supervision. This recommendation is continued and will be examined further at the next inspection. (See recommendation 1 for this quality statement). To increase the uptake of training the manager planned to develop access to the e learning system to enable staff to undertake this training in small groups. It was also planned to develop a staff training information board within the home. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 1 Inspection report continued Glennie House, page 25 of 31

26 Recommendations Inspection report continued 1. All staff should have access to regular planned supervision. National Care Standards Care Homes for Older People, Standard 5: Management and Staffing Arrangements Glennie House, page 26 of 31

27 Quality Theme 4: Quality of Management and Leadership 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 management and leadership of the service. Service strengths The grade achieved for this quality statement at the last inspection on 29 February 2012 was 3 - Adequate. Elements of the evidence provided were re-visited during this inspection and this statement regraded 4 - Good. We concluded this after we talked to residents, relatives, the manager and staff. See comments under Quality Statement 1.1. Comments from relatives included: "I feel that the manager runs Glennie House with not only complete efficiency but also compassion." Areas for improvement The service should continue to provide opportunities for residents and carers to participate in assessing and improving the quality of the management and leadership within this service. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide. Service strengths The grade achieved for this quality statement at the last inspection on 29 February 2012 was 3 - Adequate. Elements of the evidence provided were re-visited during this inspection and this statement regraded 4 - Good. We concluded this after we talked to residents, relatives, the manager and staff. The following recommendation was made at the last inspection: The provider should involve the workforce in determining the direction and future objectives of the service. Glennie House, page 27 of 31

28 National Care Standards Care Homes for Older People, Standard 5: Management and staffing arrangements Findings: As identified in quality statement 1.1 the quality assurance system included involvement of service users, carers, staff and stakeholders in assessing the quality of the service provided. Involvement of staff was encouraged through staff team meetings, supervision and staff satisfaction surveys. Staff told us that communication and team work within the home had improved. This recommendation was met. The quality assurance system included a continuous process of audit of areas and practice within the home such as care planning, medication, environment, infection control, and health and safety. The manager also collected and reviewed monthly key performance indicators of clinical needs such as falls, nutrition, infection and tissue viability. This enabled the manager to promptly identify and address issues arising in these areas. The quality assurance manager reviewed audits during regular unannounced visits to the home. The service continued to notify the Care Inspectorate as required of events within this service. Areas for improvement The service should continue to build on current good practice. Grade awarded for this statement: 4 - Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Glennie House, page 28 of 31

29 4 Other information Complaints No complaints have been upheld, or partially upheld, since the last inspection. Enforcements We have taken no enforcement action against this care service since the last inspection. Additional Information Action Plan Failure to submit an appropriate action plan within the required timescale, including any agreed extension, where requirements and recommendations have been made, will result in SCSWIS re-grading the Quality Statement within the Management and Leadership Theme as unsatisfactory (1). This will result in the Quality Theme for Management and Leadership being re-graded as Unsatisfactory (1). Glennie House, page 29 of 31

30 5 Summary of grades Quality of Care and Support Good Statement 1 Statement Good 4 - Good Quality of Environment Very Good Statement 1 Statement Very Good 5 - Very Good Quality of Staffing Good Statement 1 Statement Good 4 - Good Quality of Management and Leadership Good Statement 1 Statement Good 4 - Good 6 Inspection and grading history Date Type Gradings 29 Feb 2012 Unannounced Care and support 3 - Adequate Environment 3 - Adequate Staffing 3 - Adequate Management and Leadership 3 - Adequate All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Glennie House, page 30 of 31

31 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 the Care Inspectorate. 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@careinspectorate.com Web: Glennie House, page 31 of 31