Wyndford Locks Nursing Home Care Home Service

Transcription

1 Wyndford Locks Nursing Home Care Home Service 1 Currie Street Maryhill Glasgow G2 9EW Inspected by: (Care Commission Officer) Type of inspection: Charlie Buckle Unannounced Inspection completed on: 7 November 28 1/15

2 Service Number Service name CS Wyndford Locks Nursing Home Service address 1 Currie Street Maryhill Glasgow G2 9EW Provider Number dummy Provider Name SP BUPA Care Homes (CFHCare) Limited No Inspected By dummy Inspection Type Charlie Buckle Care Commission Officer Unannounced dummy Inspection Completed Period since last inspection 7 November 28 4 months dummy Local Office Address 4th Floor 1 Smithhills Street Paisley PA1 1EB dummy 2/15

3 Introduction Owned and managed by BUPA Care Homes Limited, Wyndford Locks Care Home has been registered with the Care Commission since the 1st of April 22 to provide residential accommodation and support to a maximum of 15 older people. Wyndford Locks Care Home is a purpose built facility within the Maryhill area of Glasgow, and is reasonably close to local amenities and transport links. The facility has five separate units that can accommodate thirty service users in each, with bedrooms being single occupancy Two units offer enhanced residential care and three units offer nursing care, two of which are for residents with dementia.. All bedrooms have en-suite facilities and there are communal and sitting and dining areas. All accommodation is provided on the one level, and is enclosed with a well maintained garden for the sole use of service users. The facility has a central administration area which includes the kitchen and laundry facilities. Wyndford Locks Care Home s aims that they will treat residents with dignity and respect, and to preserve the rights as citizens. The service employs a team of nurses, senior carers and care assistants with varying degrees of skills, expertise and qualifications. During the inspection, four Quality Themes were considered. Based on the findings of this inspection the service has been awarded the following grades: Quality of Care and Support - Quality of Environment - Quality of Staffing - Quality of Management and Leadership - This inspection report and grades represent the Care Commission s 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. Please refer to the care services register on the Care Commission s website ( for the most up-to-date grades for this service. Basis of Report This report was written following an unannounced inspection which took place on Thursday the 6th and Friday the 7th of November 28. Feedback was given to the Home Manager and the Clinical Services Manager at the end of the inspection. This report should also be read in conjunction with the report on the announced inspection which took place on the 22nd and 24th of June 28. Before the Inspection The Annual Return 3/15

4 The service submitted a completed Annual Return as requested by the Care Commission. The Self-Assessment Form The service submitted a self-assessment form as requested by the Care Commission. Views of service users The officers were able to meet with nine service users during the inspection. Regulation Support Assessment The inspection plan for this service was decided after a Regulation Support Assessment (RSA) was carried out to determine the intensity of inspection necessary. The RSA is an assessment undertaken by the Care Commission Officer (CCO) which considers complaints activity, changes in the provision of the service, nature of notifications made to the Care Commission by the service (such as absence of a manager) and action taken upon requirements. The CCO will also have considered how the service responded to situations and issues as part of the RSA. MEDIUM This assessment resulted in this service receiving a medium RSA score and so a medium intensity inspection was required. The inspection was based on the relevant Inspection Focus Areas and associated National Care Standards, recommendations and requirements from previous inspections and complaints or other regulatory activity. During the inspection process Staff at inspection This inspection was undertaken by Care Commission Officers Charlie Buckle and Ann McKinnon. Evidence For the purpose of this inspection the following documents were sampled: - Service users support plans - Risk Assessments - Food menus - Cleaning Schedules An observation of the environment throughout the home was also conducted during the inspection. Inspection Focus Areas and links to Quality Themes and Statements for 28/9 Details of the inspection focus and associated Quality Themes to be used in inspecting each type of care service in 28/9 and supporting inspection guidance, can be found at: Fire Safety Issues The Fire (Scotland) Act 25 introduced new regulatory arrangements in respect of fire safety, on 1 October 26. In terms of those arrangements, responsibility for enforcing the statutory provisions in relation to fire safety now lies with the Fire and Rescue service for the area in which a care service is located. Accordingly, the Care Commission will no longer report on matters of fire safety as part of its regulatory function, but, where significant fire safety issues become apparent, will alert the relevant Fire and Rescue service to their 4/15

5 existence in order that it may act as it considers appropriate. Further advice on your responsibilities is available at Action taken on requirements since last Inspection There were no requirements made in the last inspection. Comments on Self Assessment A completed self assessment document was previously submitted by the service. This was completed to a satisfactory standard and gave some relevant information for each of the quality themes and statements. The service identified its strengths and some areas for future development. View of Service Users The officers were able to meet with nine service users individually during the inspection. Some of the views included: Nice place here. I get on well with staff. I am not sure about my care plan. Place is very comfortable. I am not allowed to go down to the shops, staff come with me." Don t like potatoes, but everything else is fine. Very happy with the food. When you don t like something on the menu the chef will ask you what you want and you get it. View of Carers There were no carers/family members available at the time of inspection. 5/15

6 Quality Theme 1: Quality of Care and Support Overall CCO Theme Grading: 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. Since the last inspection, management were in the process of assessing current participation methodologies within the home in order to make improvements in service user and carer involvement. Progress will be assessed in the next formal inspection. Statement 2: We enable service users to make individual choices and ensure that every service user can be supported to achieve their potential A recommendation was made in the last inspection to ensure that the daily food menus reflected choices for service users who required a modified diet. Progress to Date: Evidence was available to demonstrate that menus had been adapted to include the appropriate choices for modified and special diets. This recommendation is therefore met. Further improvements were highlighted by staff and service users that the chef would regularly visits each house unit to gain feedback from service users, check satellite fridges and night time snack boxes Some service users and staff stated that food had improved recently. 6/15

7 A recommendation was made in the last inspection to ensure that appropriate risk assessments with family involvement were undertaken regarding bedroom doors being locked. Progress to Date: The officers evidenced through service users support plans that this exercise was inconsistent within the units. The practice of locking doors and restricting access had not been supported by an agreed risk assessment for many residents. This recommendation will be reiterated at the end of this report. (See recommendation1.) There were some general concerns raised during the inspection regarding a consistent approach to daily activities for service users. This was addressed with the manager during feedback who informed that she was aware of some difficulties and exploring other ideas. This will be assessed further in future inspections. 1 Statement 3: We ensure that service user's health and wellbeing needs are met. service users and carers, this service continues to have a good performance in relation to this statement. There were no areas of development in this statement, as the service was operating good standards of care. 4 - Good 7/15

8 Quality Theme 2: Quality of Environment Overall CCO Theme Grading: Statement 1: We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Since the last inspection, management were in the process of assessing current participation methodologies within the home in order to make improvements in service user and carer involvement. Progress will be assessed in the next formal inspection. Statement 2: We make sure that the environment is safe and service users are protected A recommendation was made in the last inspection to ensure improvements were made to the general cleanliness within Maryhill AND Robert Graham units. Progress to Date Cleanliness within both of these units along with Kelvindale required to improve. Presenting malodours within corridors and cleanliness in some toilets has significantly reduced standards. The cleaning schedule was being reviewed by the manager, however previous reviews appeared to have been ineffective in terms of improving cleanliness within some units, This recommendation will be reiterated at the end of this report. (See recommendation 2.) 8/15

9 A recommendation was made at the last inspection to ensure that sluice doors were locked at all times whilst not in use. Progress to Date: The officers observed that within three of the five units, practice was not consistent with many sluice areas remaining unlocked. This recommendation will be reiterated at the end of this report. (See recommendation 3.) During an observation of the environment the officers found that with Garscube unit, one of the communal bathrooms was being inappropriately used to store items of furniture and equipment. Storage of such requires to be reviewed by the manager and staff. (See recommendation 4.) 3 Statement 3: The environment allows service users to have as positive a quality of life as possible. The service should continue to review the environment to ensure that orientation prompts are appropriate and aid the service user in locating their own bedroom. 9/15

10 Quality Theme 3: Quality of Staffing Overall CCO Theme Grading: Statement 1: We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Since the last inspection, management were in the process of assessing current participation methodologies within the home in order to make improvements in service user and carer involvement. Progress will be assessed in the next formal inspection. 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. Heads of care within the units had informed that they had recently received recruitment training from their Human Resources Department. Progress regarding safer recruitment will be assessed in more detail at the next inspection. 1/15

11 Statement 3: We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. service and carers, this service continues to have a good performance in relation to this statement. There were no areas of development in this statement, as the service was operating good standards. 4 - Good 11/15

12 Quality Theme 4: Quality of Management and Leadership Overall CCO Theme Grading: Statement 1: We ensure that service users and carers participate in assessing and improving the quality of the management and leadership of the service. A recommendation had been made at the last inspection for the provider to develop and implement policy guidance in relation to service users and carer participation. Progress to Date: Management were continuing with plans for various working parties to include service users and carers. This recommendation has been met due to work in progress. Since the last inspection, management were in the process of assessing current participation methodologies within the home in order to make improvements in service user and carer involvement. Progress will be assessed in the next formal inspection. Statement 3: To encourage good quality care, we promote leadership values throughout the workforce. service and carers, this service continues to have a good performance in relation to this statement. There were no areas of development in this statement, as the service was operating good standards. 12/15

13 4 - Good 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. A recommendation was made in the last inspection to ensure that staff at all grades had access to regular formal supervision Progress to Date; Staff confirmed that supervision was more regular which also included night staff. This recommendation is therefore met. The service should continue to explore ways in which service users can be involved and informed of the quality assurance systems in place. Access to independent advocacy should be explored further. 13/15

14 Regulations / Principles National Care Standards 14/15

15 Enforcement There has been no enforcement action against this service since the last inspection. Other Information None identified. Requirements There were no requirements made during this inspection. Recommendations 1. The service should review its current practice of restricting access to service user's bedrooms. National Care Standards, Care Homes for Older People, Standard 4 (1) (6) Your Environment. 2. The provider should review the effectiveness of the cleaning schedule within Robert Graham, Maryhill and Kelvindale units in order to improve standards within the environment. National Care Standards Care Homes For Older People: Standard 4 -Your Environment. 3. The provider should ensure that all sluice doors are locked at all times and that they have an appropriate functional lock in place. National Care Standards Care Homes For Older People: Standard 4 -Your Environment. 4. The provider should review the storage of furniture and equipment within Garscube unit. National Care Standards Care Homes For Older People: Standard 4 -Your Environment. Charlie Buckle Care Commission Officer 15/15