Haylie House Residential Home Care Home Service Adults 97 Irvine Road Largs KA30 8EX Telephone:

Transcription

1 Haylie House Residential Home Care Home Service Adults 97 Irvine Road Largs KA30 8EX Telephone: Inspected by: Michael Hilston Type of inspection: Unannounced Inspection completed on: 17 April 2014

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 6 3 The inspection 11 4 Other information 26 5 Summary of grades 27 6 Inspection and grading history 27 Service provided by: Haylie House Trust Ltd Service provider number: SP Care service number: CS Contact details for the inspector who inspected this service: Michael Hilston Telephone enquiries@careinspectorate.com Haylie House Residential 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 5 Very Good Quality of Environment 5 Very Good Quality of Staffing 6 Excellent Quality of Management and Leadership 6 Excellent What the service does well We found the home to be excellent at involving service users and their carers in all aspects of the service including: care and support, the environment, staffing, and management / leadership. We saw evidence of this throughout various records, discussion with staff, service users, and carers, and we observed high quality interaction between the staff and those using the service. The staff were well-trained and their contact with those using the service were genuinely warm, caring, and supportive and we graded staffing as excellent. These high standards were supported by a dedicated management team and board of trustees, who were able to demonstrate a commitment to the promotion of person centred support and the provision of a high quality service. We graded management and leadership statements as excellent. Other statements relating to health and wellbeing and a safe environment were also of a high standard and received grades of very good. As a result of this practice, outcomes for service users was very positive. They told us that they felt well looked after. People looked happy and those we spoke with confirmed this and said that they were looking forward to taking part in the activities of the day. We saw them interacting positively with each other and the staff, in a variety of ways. Haylie House Residential Home, page 3 of 29

4 What the service could do better Inspection report continued We examined a number of records, most of which were fully completed and appeared accurate. However, some documents could benefit from having more detail and some information was not accurate. While the home appeared well maintained and in a very good state of decoration, the system for reporting and recording repairs could benefit from being more formal. What the service has done since the last inspection At the last inspection the home was found to be performing to a very good standard in all quality themes we inspected, with one quality statement being graded as excellent. Since then, they have continued to improve and, at this inspection, have been graded as very good in relation to the themes of care and support and environment. Grades of excellent have been awarded relating to the themes of staffing and management / leadership and overall 6 of the 8 quality statements we looked at were graded as excellent. Conclusion Haylie House was found to be performing to a very high standard in relation to the areas inspected and there was evidence that the outcomes for those using the service and their carers were very positive. Who did this inspection Michael Hilston Haylie House Residential Home, page 4 of 29

5 1 About the service we inspected Haylie House Residential Home is located in the coastal town of Largs. The service was registered with the Care Commission on the 1 April The service's registration certificate states a maximum of 26 older people can be cared for within the unit. The service operates from a large converted house, with two single storey extensions. The main house has two floors with a lift and disabled access. The service is managed by a Board of Trustees and has charitable status. The service's aims and objectives statement includes the following: "To provide care to meet individual needs, to encourage relatives and friends to be involved in the Home, to provide opportunities for residents to take part in activities both inside and outside the home, to actively promote choice, dignity, diversity, equality and privacy." The service was deemed registered with Social Care and Social Work Improvement Scotland (SCSWIS) on 01 April 2011 in terms of article 2 of The Public services Reform (Scotland) Act 2010 (Health and Social Care) Savings and Transitional Provisions Order 2011 (SSI 2011/121). The service was formerly registered with the Scottish Commission for the Regulation of Care (the 'Care Commission'). The Care Commission merged on 1 April 2011 with the Social Work Inspection Agency and the section of HMIE responsible for inspecting services to protect children, to form the new scrutiny body SCSWIS. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 5 - Very Good Quality of Environment - Grade 5 - Very Good Quality of Staffing - Grade 6 - Excellent Quality of Management and Leadership - Grade 6 - Excellent 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. Haylie House Residential 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 low intensity inspection. We carry out these inspections when we are satisfied that services are working hard to provide consistently high standards of care. What we did during the inspection We visited Haylie House over 3 days from the 15th April 2014 to the 17th April These included an early morning visit to meet the night staff and to observe the early morning routine including the staff changeover. During the inspection we gathered evidence from a number of sources including observation, discussion with management, staff, visiting carers, and those living in the home. We also examined a range of records and other paperwork including: Quality Statement 1.1 Self assessment - evidence of service user and carer involvement Advocacy - information Notice boards Wish tree You said we did board Activities board Newsletter Suggestion box Participation strategy Questionnaires evaluations and action plans Service user meeting minutes an action plans Relatives meetings and action plans Focus Groups Welcome Pack Involvement re environment /staffing Complaints records Photographs & records of the activity programmes Reviews Quality Statement 1.3 Personal Plans Risk assessments Haylie House Residential Home, page 6 of 29

7 Activity records, life Story books etc Medication Administration Record Sheets Written agreements Quality Statement 2.2 Policy and procedures Health and safety folder Maintenance contracts Accident and incident records Insurance certificates PAT 5 Year Electrical Test Gas safety Hot water checks COSSH Environmental Health Report Repairs book Quality Statement 3.3 Staff training records Supervision Staff meeting minutes Quality Statement 4.4 Manager's Audits 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 Haylie House Residential Home, page 7 of 29

8 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 Haylie House Residential Home, page 8 of 29

9 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. 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 service submitted a self assessment in which they were able to identify appropriate strengths and areas for development. Taking the views of people using the care service into account During the inspection we spoke with 8 service users including a focus group. All comments were very positive. Service users told us that the staff were very nice that they were polite and respectful and one described the staff as 'hand picked'. All felt that they could talk with both the staff and the management of the home at any time and that their views would be listened to. They felt involved in decisions about their care and about the environment. Seven Care Inspectorate Questionnaires were returned to us by people living in the home, all indications were positive. Taking carers' views into account During the inspection we spoke with two family members. Again all comments were very positive, they felt that the home had kept them informed and that they could raise any issues with the staff and management team and that they were confident that any issue would be responded to appropriately. We also received 8 care Inspectorate Questionnaires from carers. Most comments were positive, the only area for improvement being in relation to the accessibility of the gardens, much of which are on a slope and which allowed easy access to a main road. However we noted during the inspection that some alterations were being made at the front of the property, to allow better access. Haylie House Residential Home, page 9 of 29

10 Specific comments included: 'We could not wish for better staff or Care Home for our friend' 'I am very happy with my mother's care at Haylie House. She can come and go as she likes and I have often been invited to stay for a meal. The staff attitude is that this is their (service user's) home and should be treated as such. Whoever recruits the staff is very good at picking people suited for the job. The staff are all very friendly and several of them came in on their day off to the Christmas Party. It's a happy place.' 'The food is good, the environment is very friendly and informal and the staff are lovely. I have been made very welcome and have had some meals in the house. They provide an excellent service and I am very impressed. 'My relative can move freely about the house but not the garden, as the building is locked. This is as it should be. She is always able to come for a walk outside with me or a member of staff'' 'It has been a difficult year due to weather conditions. Even so, the staff have managed to arrange outings to events and meals in restaurants.' Haylie House Residential Home, page 10 of 29

11 3 The inspection We looked at how the service performs against the following quality themes and statements. Here are the details of what we found. Quality Theme 1: Quality of Care and Support Grade awarded for this theme: 5 - Very Good Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the care and support provided by the service. Service strengths At our last in July 2013 the service was graded as 5 - Very Good in relation to this quality statement. During this inspection evidence was examined and the service was found to have improved its performance and was graded as 6 - Excellent. Participation was a particular strength within the home. A written participation strategy was in place which set out how they intended to involve service users and carers in all aspects of the home, these included: One to one meetings Reviews Residents meetings Relatives group Focus groups Questionnaires and surveys Suggestion box Newsletter Wish tree Managers surgery One to one meetings and the managers surgery gave service users and carers the opportunity to meet and discuss specific issues with key staff. We spoke with service users who confirmed that these took place and were useful. They found staff and the manager approachable and were confident that they could raise any issues with Haylie House Residential Home, page 11 of 29

12 them. This was also confirmed by visiting family members that we spoke with during the inspection. Outcomes were good in terms of communicating issues and being able to address any problems. There was evidence that formal reviews were taking place. In cases where circumstances were changing, we saw that reviews had been held more frequently so that all parties involved could be consulted and decisions made. Individual assessments within the plan were also updated and reviewed within appropriate timescales. This meant that care provided was appropriate to the circumstances at that moment. Minutes evidence that residents meetings were taking place and that these were attended by a good number of residents. Minutes showed that residents were consulted on a variety of issues including meals and the environment. Meetings were used to update residents on what was happening in the home including activities and any proposed changes. Action plans were drawn up following meetings to ensure that issues raised were attended to in a timeous manner. Issues raised by service users included: better use of outside space and the growing of vegetables, suggestions for outings, laundry issues, food, and the dining experience. We could see evidence that these issues had been addressed. While we were in the home workmen were in the process of working in the garden to make a safe area for service users in order that they could have more access to it as requested. The dining experience had also been changed taking into account the views of those living in the home and they told us that the changes were positive. While there had been issues regarding lost laundry minutes we noted that service users had found that this had improved. In addition to routine meetings the home also held focus groups on specific topics such as menus and the changes to the dining experience. There was evidence that relatives meetings had also been held, information was passed about various developments and they were also used as a platform for external speakers of interest to the group including the dementia liaison nurse and board members. Minutes evidenced that relatives were encouraged to participate and give opinions on various topics including the home's self-assessment. Relatives we spoke with confirmed that they were consulted, kept informed, and said that the management and staff were very approachable. Minutes of meetings included discussion of: the dining experience, wish tree, 'you said we did', the use of Skype, fund-raising, the garden project, self-assessment, and anticipatory care planning. There was also evidence from carers that they had been involved in various events in the home and in the community with the staff and their relative, for example a charity walk. These events ensured that links were maintained Haylie House Residential Home, page 12 of 29

13 with the community and that the service users were still playing an active part in events in Largs. As noted above we saw evidence from a number of sources that service users and carers were involved in the self-assessment process. We asked service users what they thought of the home in terms of grades and they all agreed that it should be given grades of very good and excellent. They agreed that they were asked about their care, the environment, and activities, they said staff were approachable and that they were listened to. The home had on display the contact number for North Ayrshire Advocacy Service which service users and carers could contact should they need assistance or advice. An AIMS advocacy leaflet was also available. So that service users and carers knew who to talk to staff photographs were on display with their names and any specific role that thy held in the home, and we were told by visiting relatives that this had been very helpful. The board of trustees photographs were also on display. During the inspection we saw at least 2 board members in the home and this along with their attendance at meetings gave service users and their carers the opportunity to talk to them directly. There were lots of examples of service users and family members being consulted about the environment. Questionnaires asked about this and about the quality of staffing. We could see from records of staff recruitment that service users had been involved in the process. Appointable candidates were introduced to service users who were then asked to comment on their suitability and whether they should be appointed. This information was clearly documented within recruitment records. In this way service users could select staff that they felt comfortable with. We asked service users about the staff and all said that they were very good, one service user said that they were 'hand picked'. The interactions we observed evidenced that service users received friendly and caring support. Throughout the home there were a number of notice boards giving service users and carers information on a range of subjects, including the Care Inspectorate's last inspection report. In addition there were wish trees where service users could hang tickets with requests and these were actioned where possible and results transferred to a 'you said we did board' also on display. The home had a newsletter the most recent issue had been in April 2014, items included: dates for the diary which informed people of events planned including a bingo night at the bowling club, an outside entertainer, therapist visit, and a planned hairdresser's visit. Other articles included birthday celebrations, fundraising and Haylie House Residential Home, page 13 of 29

14 poetry. The newsletter was also used to inform people about the manager's surgery, and the 'you said we did board'. One additional article reported that there had been a meeting held to discuss the home's self-assessment with relatives and staff attending. This newsletter was a good tool to inform service users and carers of what was happening in the home and to keep them up to date regarding opportunities to participate. A quality assurance survey was conducted annually and opinions were sought from service users, carers, staff and other stakeholders such as visiting professionals. The survey asked people to comment on a range of areas such as: Care and support Dignity and respect Privacy Complaints Participation Approachability of staff Cleanliness of the environment Laundry Food The most recent quality survey of April 2014 was in the process of being completed at the time of the inspection. The results of the resident survey questionnaires had been collated and we saw that 81 % of residents had been involved. The results included that: 100% felt that they were well cared for in Haylie House, 100% felt that the staff treated them with dignity and respect, 95% said their privacy was respected, 90% felt that they had the opportunity to express their views, 100% felt that their family and friends were welcomed to the home, 100% felt that the managers were approachable. Forty five individual comments were positive only 3 indicated some areas of dissatisfaction. Some relative questionnaires had been returned at the point of the inspection but had not yet been collated. We read those which had been returned and all were very positive about the care received by their relatives. Only one made any negative comment regarding laundry issues and this has been noted within the minutes of other meetings. A suggestion box was in place but this had not been well used by service users or their carers and had been replaced in effect by the wish tree. While no suggestions had been received via the suggestion box, the wish tree had been much more successful at capturing these. The management said that, as a result, they would probably remove the box. Haylie House Residential Home, page 14 of 29

15 Haylie house had an introductory pack (prospectus). This complements the information in the written agreement and included information including: A brochure Aims and objectives of the service How to apply for residency Charter of rights Complaints procedure Participation Sample menu Visiting arrangements Closure arrangements A complaints procedure and recording system were in place but no complaints had been received by the care service. Areas for improvement While review meetings were well evidenced, management said that, on occasion, receipt of the minutes of social work reviews had been delayed. In order to ensure that up t date minutes of meetings were always in place, the home should take an independent minute of the meeting and ensure this is placed in the file until social work's paperwork is received. Although action plans were drawn up for residents', relatives' and other meetings, these were held in a separate folder from the minutes. The process could be improved by including the action plan in the minutes. The care inspectorate's local office address should be updated on one document, as it gives our previous address. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Statement 3 We ensure that service users' health and wellbeing needs are met. Haylie House Residential Home, page 15 of 29

16 Service strengths Inspection report continued At our last inspection in July 2013 the service was graded as 5 - Good in relation to this quality statement. During this inspection evidence was examined and the service was found to have maintained its performance and was again graded 5 - Very Good. Each service user had a personal plan containing all of the relevant information required by the regulations. Personal plans were person centred, detailing personal preferences about how the care was to be provided including: the time the person likes to get up and go to bed, preferences as to having a shower or bath, the preferences as to the gender of their carer, and whether the person wanted a key to their room. This was all evidence of good person centered practice, and there was evidence from service users and their carers that their preferences were respected. Since our last inspection personal plans had again been further developed. We found them to be holistic incorporating assessment of health and social care needs. A range of relevant assessment tools were used in accordance with best practice, these included individual risk assessments and environmental risk assessments. Plans included a life story section which helped staff to know the person they were looking after. Areas considered in the plan included: Personal care Mobility Communication Eating and drinking Sleeping, oral hygiene Foot care Falls Medical history Medication Meaningful activities Spiritual needs Future wishes Although Haylie House does not offer nursing care from the examination of personal plans and other records there was evidence of referral to the appropriate health care professional as appropriate such as the dietician, GP, and podiatrist. In addition to formal review meetings each of these areas was reviewed on a regular basis which ensured the plan was up to date and relevant to the current needs of the service user. Accident and incident records were in place along with appropriate audits and action plans. Haylie House Residential Home, page 16 of 29

17 Activity records showed that there were a variety of outings and in-house activities taking place such as: Millport trip Grand National event Theatre Coffee mornings Burns celebration Christmas day celebration where a local school visited and sang carols St Andrews day party Clothing party Food glorious food competition - Haylie House's entry was a clootie dumpling made by the residents Guy fox night including a fireworks display Visits to local museums Leisure exercise class Fun run / walk - September 2013 article in the Largs and Millport weakly news. Residents along with around 20 staff, family and friends took part. Live music Birthday celebrations Adults with incapacity (AWI) Certificates were in place as appropriate and each was accompanied with a relevant treatment plan. We examined Medication Administration Recording Sheets and found those sampled to be clear and fully completed. We asked for the written agreements of 4 service users which we selected at random. The agreement included the aims objectives and principles of the service, the cost of the service and how this will be paid, the accommodation, the care to be provided, and a list of extras and their cost for example hairdressing, chiropodist, and newspapers. Also included were arrangements for managing person finances where required, and insurance arrangements. Arrangements for terminating the agreement also were clearly detailed. Areas for improvement The home had a good safety briefing form for staff, indicating if there are any specific health or safety issues relating to service users, for example specific infection. However, this tended to list these by room number. It would be better if names were used, as this is more person centred and would reduce the opportunity for misinterpretation. Haylie House Residential Home, page 17 of 29

18 As noted, personal plans were again being further developed and each plan still had replaced paperwork in place, in addition to the new paperwork. In some cases we noted inconsistencies across documents and it would be better if older documents where information had been transferred were archived. Some information in plans was not always sufficient in detail, some was inaccurate and some information on newly introduced Advance Care Planning documentation was incomplete (See Requirement) Not all service users had a written agreement in place, which had been signed by them or their representative. We found that one of the four service user's files sampled did not have a signed plan and, although there was evidence that the home had asked for this to be completed 7 months earlier, this had not been returned and this should have been followed up. (See Recommendation). Grade awarded for this statement: 5 - Very Good Number of requirements: 1 Number of recommendations: 1 Requirements 1. The provider must ensure that information personal plans is accurate, fully complete, and contains sufficient information to direct how the assessed needs are to be met. This is in order to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) - regulations 4(1)(a). Timescale for meeting this Requirement: within 1 month of receipt of this report. Recommendations Inspection report continued 1. All service users should have a written agreement setting out the terms and conditions for receiving the service. National Care Standards for Support Services Standard 3: Your legal rights. Haylie House Residential Home, page 18 of 29

19 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 See Quality Statement 1.1 Areas for improvement See Quality Statement 1.1 Grade awarded for this statement: 6 - Excellent 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 At our last inspection in July 2013 the service was graded as 5 - Very Good in relation to this quality statement. During this inspection evidence was examined and the service was found to have maintained its performance and was again graded as 5 - Very Good. Entry to the home was secure and controlled by a key pad system and signing in procedures were in place. The home had appropriate individual and environmental risk assessments in place and there was evidence that relevant safety checks were being carried out. A range of maintenance contracts were seen including gas, hoists, and lift, and there was evidence of annual servicing of equipment. Shower-heads were being cleaned quarterly and legionella testing taking place as was portable appliance testing and a 5 Year Electrical Test Certificate was seen. We sampled the home's records of accidents which detailed the nature of the accident location and who was involved, a section headed additional comments Haylie House Residential Home, page 19 of 29

20 detailed action to minimise the risk of reoccurrence. Most records were very well completed. We also examined the home's incident records for the past year. No concerns were raised and all action appeared appropriate. Most incident records also included an action plan, to minimise risk of reoccurrence. We noted that the home were using best practice guidance for managing falls and saw that service users had individual, multi factorial falls risk assessments in place. A range of policies/procedures were available to support this quality statement including health and safety policies. There was evidence that staff had been trained in the protection of vulnerable adults. The home's recording system for residents petty cash had been improved since our last inspection by including a double signature at the time of deposits and withdrawals rather than the single signature. A range of COSHH assessments were in place, as were a number of safety data sheets for the use of chemicals in the home. Staff had received training in appropriate use of these chemicals. There was informal evidence that repairs were being conducted and the environment looked clean, tidy, free from any obvious hazards and very well maintained. Public Liability Insurance was in place. Areas for improvement Although service users had a falls risk assessment in place in line with best practice, there was no overall falls risk assessment for the home and this should be carried out. We had no concerns about the maintenance of the environment, which was of a very good standard. However, the system for reporting and completion could benefit from being more detailed. Shower temperatures were recorded at 1 Degree Celsius above recommended limits and these should be reduced. All other water temperatures were within appropriate limits. Grade awarded for this statement: 5 - Very Good Number of requirements: 0 Number of recommendations: 0 Inspection report continued Haylie House Residential Home, page 20 of 29

21 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 6 - Excellent Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths See Quality Statement 1.1 Areas for improvement See Quality Statement 1.1 Grade awarded for this statement: 6 - Excellent 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 At our last in July 2013 the service was graded as 5 - Very Good in relation to this quality statement. During this inspection evidence was examined and the service was found to have improved its performance and was graded as 6 - Excellent. Throughout this inspection we had the opportunity to observe staff practice both in terms of staff meetings and staff interaction with service users. We observed the handover meeting from the night shift to the day shift. It was good to see that at the start of the meeting that in addition to care staff ancillary staff were also present. In this way important information could be passed to all involved, this was important as we saw kitchen staff and others interacting with service users throughout the day. Our observation of staff practice throughout the inspection evidenced a warm, caring, and pleasant relationship. We saw care staff interacting in a cheery way, encouraging service users to participate in conversation and activities and assisting and supporting them in a variety of ways. It was the quality of this interaction that resulted in this quality statement being assessed as excellent. Service users and family Haylie House Residential Home, page 21 of 29

22 members spoke very highly of the staff and the management and felt that they could be approached at any time. They were confident that they would be listened to and their comments taken on board. There was evidence of staff meetings taking place. The maintenance of good practice was emphasised throughout as was the importance of consultation with service users and giving them choice. Minutes indicated that training, supervision, and registration with the SSSC were all up to date. Staff interviewed appeared to be well motivated and practice discussed was in line with the National Care Standards. A number of best practice documents were being used by the service. Staff spoke positively of service users and were well-informed regarding their care and support needs. The home have an induction programme for new staff and those interviewed said that they had received training, regular supervision and staff meetings. The manager conducted a monthly training audit. Staff training included a mix of core training and additional courses such as: Moving and assisting Infection control Food safety Adult support and protection Medication Falls Dementia Oral hygiene Nutrition Continence A number of staff had either completed or were undertaking SVQ Some senior staff had undertaken specific training in leadership in dementia and a number of staff had specific roles as champions for various areas including: continence, oral health, nutrition, hearing, falls, and shopping. This information along with their photographs was on display so that service users and family members could identify who to talk to if they wished to raise a specific issue about one of those areas. Areas for improvement Although action plans were drawn up for meetings these were held in a separate folder from the minutes. The process could be improved by including the action plan in the minutes. Haylie House Residential Home, page 22 of 29

23 While there was a comprehensive system for recording training this was in the process of being reviewed to make it easier to produce a clear overview of staff training need and this should continue. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Inspection report continued Haylie House Residential Home, page 23 of 29

24 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 6 - Excellent 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 See quality statement 1.1 Areas for improvement See quality statement 1.1 Grade awarded for this statement: 6 - Excellent 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 At our last in July 2013 the service was graded as 6 - Excellent in relation to this quality statement. During this inspection evidence was examined and the service was found to have maintained its performance and was graded as 6 - Excellent. During the inspection, we spoke with members of the board, managers and staff. Through these discussions we could see that there was evidence of a clear commitment at all levels to the provision of a high quality, person centred service. The home had an extensive programme of continuous improvement and there was evidence of regular consultation with service users and carers. There was evidence of recording, analysis, evaluation and action planning, to improve the experience of those living in the home. The home had a very comprehensive process for self-evaluation, audit, progress monitoring and feedback, in order to ensure that the quality of the service was maintained and improved upon. The quality assurance process included seeking the views of other stakeholders, including visiting professionals. Quality assurance Haylie House Residential Home, page 24 of 29

25 included all those methods described in quality statement 1.1, which were supported by a comprehensive auditing system of core areas including: Protected activity time Staff meetings Accidents Personal plans Health and safety Reviews Residents meetings Weights Supervision Oral hygiene Medication administration records Recruitment Questionnaires Equipment Although these audits would be expected within any care service, Haylie's commitment to the full process was excellent in particular action planning, accountability, follow-up and reporting. The outcome for service users was excellent, as areas identified for improvement were addressed and continuously monitored. Areas for improvement The service should continue to build on current practice. Grade awarded for this statement: 6 - Excellent Number of requirements: 0 Number of recommendations: 0 Haylie House Residential 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 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 the Care Inspectorate re-grading a Quality Statement within the Quality of Management and Leadership Theme (or for childminders, Quality of Staffing Theme) as unsatisfactory (1). This will result in the Quality Theme being re-graded as unsatisfactory (1). Haylie House Residential Home, page 26 of 29

27 5 Summary of grades Quality of Care and Support Very Good Statement 1 Statement Excellent 5 - Very Good Quality of Environment Very Good Statement 1 Statement Excellent 5 - Very Good Quality of Staffing Excellent Statement 1 Statement Excellent 6 - Excellent Quality of Management and Leadership Excellent Statement 1 Statement Excellent 6 - Excellent 6 Inspection and grading history Date Type Gradings 29 Jul 2013 Unannounced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 21 Nov 2012 Unannounced Care and support 4 - Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership Not Assessed 30 Jul 2012 Unannounced Care and support 4 - Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good Haylie House Residential Home, page 27 of 29

28 2 Dec 2011 Unannounced Care and support 4 - Good Environment 3 - Adequate Staffing Not Assessed Management and Leadership Not Assessed 6 Dec 2010 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing Not Assessed Management and Leadership Not Assessed 30 Aug 2010 Announced Care and support 4 - Good Environment Not Assessed Staffing Not Assessed Management and Leadership 4 - Good 5 Mar 2010 Announced Care and support 4 - Good Environment Not Assessed Staffing 4 - Good Management and Leadership Not Assessed 20 Jul 2009 Announced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 3 Mar 2009 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 23 Jun 2008 Announced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Haylie House Residential 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 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: Haylie House Residential Home, page 29 of 29