Davislea Home For The Elderly Care Home Service Adults 100 Mallaig Road Drumoyne Glasgow G51 4PE Telephone:

Transcription

1 Davislea Home For The Elderly Care Home Service Adults 100 Mallaig Road Drumoyne Glasgow G51 4PE Telephone: Type of inspection: Unannounced Inspection completed on: 27 February 2015

2 Contents Page No Summary 3 1 About the service we inspected 4 2 How we inspected this service 6 3 The inspection 13 4 Other information 30 5 Summary of grades 31 6 Inspection and grading history 31 Service provided by: Glasgow City Council Service provider number: SP Care service number: CS If you wish to contact the Care Inspectorate about this inspection report, please call us on or us at enquiries@careinspectorate.com Davislea Home For The Elderly, page 2 of 34

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 3 Adequate Quality of Staffing 4 Good Quality of Management and Leadership 4 Good What the service does well The service provides care and support in an individual and person centred way. Staff are friendly and support residents in a dignified manner. What the service could do better The service is looking quite tired in lots of areas and although we are mindful that the home will be moving premises, there are some areas that could be maintained better in the meantime. The service could work on the resident's personal plans to make sure that there is always an up to date plan in place to inform staff how to support each resident. What the service has done since the last inspection The service has worked hard to meet some of the majority of requirements and recommendations from the previous inspection. Conclusion Davislea now has a stable staff group who know the resident's care and support needs well. A new manager has recently started and had lots of ideas for improving the service. Davislea Home For The Elderly, page 3 of 34

4 1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Information about all care services is available on our website The service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April If we are concerned about some aspect of a service, or think it could do more to improve its service, we may make a recommendation or requirement. A recommendation is a statement that sets out actions the care service provider should take to improve or develop the quality of the service but where failure to do so will not directly result in enforcement. A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reforms (Scotland) Act 2010 and Regulations or Orders made under the Act or a condition of registration. Where there are breaches of the Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Inspectorate. Davislea Care Home provides residential care for 35 older people. The provider of the care home service is Glasgow City Council. Staff are available over 24 hours. The building was built for purpose in 1962 and is long established in the community. There are three floors and each floor has a small kitchen and communal facilities including a lounge, smoking room, toilets and bath and shower rooms. There is a specialised dementia unit for up to 5 people in the annex of the home. The aim of the service is to provide a safe, caring environment in which service users are encouraged to maintain independence and make choices regarding their lifestyle. Davislea Home For The Elderly, page 4 of 34

5 Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade Quality of Environment - Grade 3 - Adequate Quality of Staffing - Grade Quality of Management and Leadership - Grade 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. Davislea Home For The Elderly, page 5 of 34

6 2 How we inspected this service The level of inspection we carried out In this service we carried out a high intensity inspection. We carry out these inspections where we have assessed the service may need a more intense inspection. What we did during the inspection We wrote this report following an unannounced inspection. This was carried out by two inspectors and an inspection volunteer. The inspection took place on Tuesday 24 February 2015 between 9.30am and 3.45pm. It continued the following day, Wednesday 25 February 2015 from 07.40am until 2.15pm. We gave feedback to the manager and service manager on 27 February As part of the inspection, we took account of the completed annual return and selfassessment forms that we asked the provider to complete and submit to us. We sent twenty care standards questionnaires to the manager to distribute to residents. Nine residents returned a completed questionnaire. We also sent twenty care standards questionnaires to the manager to distribute to relatives and carers. We did not receive any completed questionnaires before the inspection. During the inspection process, we gathered evidence from various sources, including the following: We spoke with: - Residents - Relatives - The manager - Senior care workers - Social care workers We looked at: - Insurance certificate - Accident and incident reports - Support plans - Six monthly reviews - Training records - Staff Induction - Duty rotas Davislea Home For The Elderly, page 6 of 34

7 - Staff supervision - Minutes of resident meetings - Minutes of staff meetings - Medication records - Dependency records - Quality assurance systems We used the Short Observational Framework for Inspection (SOFI 2) to directly observe the experience and outcomes of people who were unable to tell us their views It would be useful to read this report along with the inspection report dated 4 September 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 Davislea Home For The Elderly, page 7 of 34

8 What the service has done to meet any requirements we made at our last inspection The requirement Requirement 1, quality theme 1, statement 1 Where a resident is at risk of malnutrition, appropriate action must be taken in accordance with best practice guidance. The provider must ensure that if someone is assessed as needing a specialised diet this must be provided. This is to comply with SSI 2011/210, Regulation 4(1)(a) a requirement to make proper provision for the health and welfare of Service Users. Timescale: three months from receipt of the report. What the service did to meet the requirement This is discussed under quality theme 1, statement 3. The requirement is: Met - Within Timescales The requirement Requirement 2 under quality theme 1, statement 3 The provider must ensure that all staff are competent in administering medication and in keeping medication records which are safe, up to date, complete and accurate. This also includes all aspects on the safe storage of medication. This is to comply with SSI 2011/210 Regulation 4(1)(a) a requirement to make proper provision for the health and welfare of service users. Timescale: within three months on receipt of this report. What the service did to meet the requirement This is discussed under quality theme 1, statement 3. The requirement is: Met - Within Timescales Davislea Home For The Elderly, page 8 of 34

9 The requirement Requirement 3 under quality theme 1, statement 3 The provider must improve the assessment and a care planning process to reflect the assessed needs of residents in line with best practice guidance and evidence how the plan is being followed on a daily basis. This is to comply with SSI 2011/210 Regulation 4(1)(a) a requirement to make proper provision for the health and welfare of service users. Timescale: within six months on receipt of this report. What the service did to meet the requirement This is discussed under quality theme 1, statement 3. The requirement is: Not Met Inspection report continued The requirement Requirement 1 under quality theme 2, statement 2 The provider must ensure that appropriate assessment of the health and wellbeing needs are completed to allow appropriate use of the dependency assessment tool used by the service to identify the direct care and support hours of service users. This is to comply with SSI 2011/210 Regulation 4(1)(a) a requirement to make proper provision for the health and wellbeing of service users. Timescale: within one month on receipt of this report What the service did to meet the requirement This is discussed under quality theme 2, statement 2. The requirement is: Met - Outwith Timescales The requirement Requirement 2 under quality theme 2, statement 2 The provider must ensure that all areas of the home that should not be accessed by residents or visitors are kept locked at all times. They must also ensure that there is adequate provision of fobs for all members of staff at all times where their job role dictates this. Davislea Home For The Elderly, page 9 of 34

10 This is to comply with SSI 2011/210 Regulation 4(1)(a) requirement to make proper provision for the health and wellbeing of service users. Timescale: immediate for doors to be locked and one month from receipt of report for fobs. What the service did to meet the requirement This is discussed under quality theme 2, statement 2. The requirement is: Met - Within Timescales Inspection report continued The requirement Requirement 1 under quality theme 3, statement 3 The provider must ensure that all new staff have induction training within the three month induction period as described in the providers own procedures. This is in order to comply with The Social care and Social Work Improvement Scotland (Requirements for Care Services) Regulations (SSI 2011/210) regulation 15 (b)(i). Timescale within three months of the report. What the service did to meet the requirement This is discussed under quality theme 3, statement 3. The requirement is: Met - Outwith Timescales The requirement Requirement 1, under quality theme 4, statement 4 The provider must make sure that robust and accountable ways of carrying out regular and adequate monitoring and audit of resident experience and outcomes and staff practice are introduced. This is to comply with SSI 2011/210 Regulation 4(1) a regulation relating to the welfare of service users Timescale: within three months of receipt of the report. What the service did to meet the requirement This is discussed under quality theme 4, statement 4. The requirement is: Met - Within Timescales Davislea Home For The Elderly, page 10 of 34

11 The requirement Requirement 2, under quality theme 4, statement 4 Inspection report continued The provider must improve the assessment and a care planning process to reflect the assessed needs of residents in line with best practice guidance and evidence how the plan is being followed on a daily basis. This is to comply with SSI 2011/210 Regulation 4(1)(a) a requirement to make proper provision for the health and welfare of service users. Timescale: Three months from receipt of this report. What the service did to meet the requirement This is discussed under quality theme 4, statement 4. The requirement is: Met - Within Timescales What the service has done to meet any recommendations we made at our last inspection These are discussed throughout the report. 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 provider. We were satisfied with the way the provider completed this and with the relevant information included for each heading that we grade services under. The service completed the self-assessment before the inspection in September 2014 and therefore we did not ask the service to complete another before this inspection. Davislea Home For The Elderly, page 11 of 34

12 Taking the views of people using the care service into account These are reflected throughout the statements of the report. Taking carers' views into account These are reflected throughout the statements of the report. Davislea Home For The Elderly, page 12 of 34

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: 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 this inspection we focused on the areas for development from the previous inspection carried out on 4 September After we reviewed the information we gathered during the inspection process, we decided that the service had continued to perform in this quality statement at a good level. We repeated a recommendation at the previous inspection that consideration should be given to how improvements can be made to gather feedback from people with communication difficulties or cognitive impairment. We found that although there were no formal methods in place, we saw throughout the inspection that staff continually offered choice and asked for resident's opinions about their day. Staff we spoke with were able to tell us about how they communicated with people who had communication difficulties or cognitive impairment. This recommendation had been met. We found that meetings had been re-established with the new catering manager and that feedback from the residents was discussed regularly. This included ways of taking any suggestions forward. We saw some menus changes had also been discussed at resident meetings. We looked at six monthly reviews for residents and found that the resident or their family representative was involved in these. The benefit of this was that they were involved in future planning of how the best ways with which the service could support them. Davislea Home For The Elderly, page 13 of 34

14 There was an inspection volunteer involved in the inspection. An inspection volunteer is a member of the public who volunteers to work alongside the inspectors. Inspection volunteers have a unique experience of either being a service user themselves or being a carer for someone who has used services. The inspection volunteer role is to speak with people using the service being inspected and gathering their views. The inspection volunteer involved in the inspection talked to residents and their relatives, comments included: "It's quite good" "care is fine" "get well looked after" "care is great" "care is fairly good" "food is very good" "food is so so" "there is a choice if you do not like something" "food - sometimes better than others" "food is alright" "Food can come and go. They do their best - sometimes better than others" "I enjoy some of the activities especially a Saturday night" "have just attended first review meeting" "carers state X (resident) eats okay" "X (resident) loves the activities." Areas for improvement We repeated a recommendation at the previous inspection that the provider needs to make sure that when comments, suggestions and concerns are raised that they are addressed promptly. We found that meetings had taken place in each unit of the service with some residents. However, minutes from these did not show how any suggestions or ideas were taken forward and how the residents were kept informed. We saw that a new 'You Said, We Did' space had been recently created on notice boards and this would be good idea to take forward. This recommendation had not been met and will be repeated. See recommendation 1, detailed below. The service should build on their current methods of involving the residents, relatives and staff in the assessment and improvement of the service and consider the best way to evidence how their involvement has influenced change in the home. We discussed various ideas with the manager and service manager. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 1 Davislea Home For The Elderly, page 14 of 34

15 Recommendations Inspection report continued 1. The provider should make sure that when comments, suggestions and concerns are raised that they are addressed promptly. National Care Standards, Care Home for Older People, Standard 11: Expressing your views. Davislea Home For The Elderly, page 15 of 34

16 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths At this inspection we focused on the areas for development from the previous inspection carried out on 4 September After we reviewed the information we gathered during the inspection process, we decided that the service had performed in this quality statement at a good level. We repeated a requirement at the previous inspection that when a resident is at risk of malnutrition, appropriate action must be taken in accordance with best practice guidance. Also, that the provider must ensure that if someone is assessed as needing a specialised diet, this must be provided. We found that since the last inspection staff had received training in the Malnutrition Universal Screening Tool (MUST) to assist with recognising those residents that were at risk. We saw some good examples of where this had been used well and resulted in input from GP and dietician with a positive outcome for the resident. We found that specialised diets were provided including a fortified diet for those who needed this. Staff were able to tell us how they fortified people's diets both during meals and in between meals. Staff used their knowledge of residents to assist with this process. This requirement had been met. We found that residents were offered plenty of fluids throughout their day and that staff offered encouragement to residents where this was needed. The benefit of this was that residents were assisted to keep hydrated. We repeated a requirement at the previous inspection in relation to staff competency when administering medication and in keeping medication records which were safe, up to date and accurate. This also included all aspects of safe storage of medication. We found that medication was stored securely. We saw that medication competency assessments had taken place with staff and that staff we spoke with told us that this had been useful. We found that records of administration were clear and accurate for all currently prescribed medication. This requirement had been met. Davislea Home For The Elderly, page 16 of 34

17 We repeated a recommendation at the previous inspection that personal plans should include the health and wellbeing needs of the residents and provide clear direction on how resident's preferences are to be met. This mainly related to having more activities whilst living at the home. We found that personal plans contained a good level of information about what activities and hobbies they enjoyed before coming to the home and what areas they would like to be part of whilst staying at the home. Residents we spoke with told us that they enjoyed the activities in the home, especially the social night at the weekend. We saw some activities throughout the inspection including bingo, board games and music. We saw that one resident had asked at their previous review to spend more time outside and that at their more recent review they said that this had happened. This recommendation had been met. We sent out 20 questionnaires to residents prior to the inspection and received nine back. Eight of the residents said that they either agreed or strongly agreed that they were overall happy with the care and support that they received whilst one person disagreed with this. Their comments were: "I feel the home has most things covered, people have so many different needs and they are attended to, staff are busy all of the time." 'The staff naturally automatically support me when I'm upset." "All fine." "The staff here are great and give me anything I want within their ability." "I like the layout of the home." "I feel there is not enough staff and some staff are not trained to do the job required, for example most agency workers are not trained and are a waste of space." There was an inspection volunteer involved in the inspection. An inspection volunteer is a member of the public who volunteers to work alongside the inspectors. Inspection volunteers have a unique experience of either being a service user themselves or being a carer for someone who has used services. The inspection volunteer role is to speak with people using the service being inspected and gathering their views. The inspection volunteer's observations were: "Residents and carers appeared, on the whole, happy with the care received. I observed staff caring for residents and appeared to have as good rapport with them. Davislea Home For The Elderly, page 17 of 34

18 I joined residents at lunchtime. It was an enjoyable experience. It was peaceful and residents chatted to each other whilst enjoying their meal. I did not observe any activities taking place in the morning of my visit. In one lounge, they were playing music which the residents really enjoyed. The remaining lounges had TVs on in them. After lunch, in one of the lounges, a staff member was playing dominoes with some of the residents. The staff member included in the conversation those residents who were unwilling or unable to play. I understood that board games were due to be played in the other lounges." Areas for improvement We repeated a requirement at the previous inspection in relation to the service improving the assessment and care planning process as the timescale for completion at that point had not yet been reached. We found that care plans were person centred and gave good detail about who the person was and what was important to them. We found that the quality of risk assessments in place and these being used to inform the care plans varied greatly which meant that not all personal plans could be used to clearly direct staff. We found it difficult to establish when medications had been changed or stopped and that care plans for these were not up to date. We saw that the MUST tool was not routinely used, but used when staff felt that someone was at risk. We were concerned that there was no personal plan in place for a resident who had been in the home for just over three months. This requirement was not met and will be repeated. See requirement 1, detailed below. We repeated a recommendation at the previous inspection in relation to the service introducing a formal auditing system for care planning within the home. We found that this process had started but was not yet fully in place. This recommendation had not been met and will be repeated. See recommendation 1, detailed below. Whilst we found that the provision for nutrition, including a fortified diet, was better than at out last inspection, we felt that there were still some areas that could be improved on. This included having more snack options that were not always sweet based, for example we saw and were told that biscuits were a frequent option. We discussed various ideas with the manager. We found that only one unit kept snack options whilst staff in the other units had to go to the kitchen each time they wanted something. We suggested having snacks kept in each servery as this may be easier to manage. We will review this at our next inspection. Davislea Home For The Elderly, page 18 of 34

19 We observed that breakfast was at a set time and that the majority of residents attended the main dining rooms for this. This meant that those residents that were up early had to wait until 9.30am. We discussed the morning routine with the manager and have asked them to consider a more flexible approach, perhaps being able to offer a continental breakfast within each unit. We will review this at our next inspection. Grade awarded for this statement: Number of requirements: 1 Number of recommendations: 1 Requirements 1. The provider must ensure that each service user has an up to date personal plan which sets out how the service user's health, welfare and safety needs are to be met. In order to do this you must ensure that: a) A plan is in place within 28 days of the date on which the service user first received the service. b) Service user's care and support needs are recorded accurately in their care plan. c) When there are any changes that the care plan is updated at the time to reflect this. d) The outcome of risk assessments are used to inform the care plan. This is to comply with The Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) - regulation 5 (1). Timescale: within four months of receipt of this report. Recommendations 1. The service should fully implement a formal auditing system in accordance with best practice guidelines in record keeping for care planning within the home. National Care Standards, Care Standards for Older People: Standard 5, Management and staffing arrangements. Davislea Home For The Elderly, page 19 of 34

20 Quality Theme 2: Quality of Environment Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of the environment within the service. Service strengths At this inspection we focused on the areas for development from the previous inspection carried out on 4 September After we reviewed the information we gathered during the inspection process, we decided that the service had continued to perform in this quality statement at a good level. There was an inspection volunteer involved in the inspection. An inspection volunteer is a member of the public who volunteers to work alongside the inspectors. Inspection volunteers have a unique experience of either being a service user themselves or being a carer for someone who has used services. The inspection volunteer role is to speak with people using the service being inspected and gathering their views. The inspection volunteer involved in the inspection talked to residents and their relatives, comments included: "is warm enough" "I have a nice room" "nice room - no complaints" "I even have some of the pictures that I have done in my room" "love out in the garden" "room is comfortable and is personalised" "home is spotless" "kept warm." The inspection volunteer's observations were: "I observed the home to be clean and comfortably warm." See service strength under quality theme 1, statement 1 for more information. Davislea Home For The Elderly, page 20 of 34

21 Areas for improvement See areas for improvement under quality theme 1, statement 1 for more information Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Davislea Home For The Elderly, page 21 of 34

22 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths At this inspection we focused on the areas for development from the previous inspection carried out on 4 September After we reviewed the information we gathered during the inspection process, we decided that the service had continued to perform in this quality statement at an adequate level. We repeated a requirement at the previous inspection in relation to the service ensuring that appropriate assessments of health are completed to allow appropriate use of the dependency tool used by the service to direct care and support hours. We found that this had been re-introduced since January We also looked at staff rotas and considered our observations during the inspection. This requirement had been met. We made a requirement at the previous inspection that the provider must ensure that all areas of the home that should not be accessed by residents or visitors are kept locked at all times. Also, that there must be adequate provision of fobs for all members of staff at all times where their job role dictates this. We found that areas were locked as expected. We asked staff about fobs and observed that staff and some residents had these. This requirement had been met. We repeated a recommendation at the previous inspection that the service should consider how it can enhance the environment for service users with the creation of an enclosed garden as the timescale for completion was not yet reached. We found that the garden area outside the dementia unit was enclosed but not secure due to the gates at the side being open and without a lock. However, we spoke with staff and they were able to tell us how residents accessed the garden and how they managed this within the staffing levels. We asked the service to continue to look at making the garden secure but we were satisfied that the garden was used by residents. This recommendation had been met. Areas for improvement At the previous inspection we asked the service to address two areas where we found a strong offensive smell. During this inspection we did find any areas of strong offensive smell but did find one bedroom and one other area of the home where odour management could be better. We discussed this with the manager and asked them to look at ways to resolve this. Davislea Home For The Elderly, page 22 of 34

23 At the previous inspection the service had been without a maintenance person and some areas had needed addressed including broken toilet seats and broken bin lids. We found that the toilet seats had been replaced, however, there were still several bins that either had missing or broken lids and could not be foot operated. At the previous inspection we were told that the maintenance person was currently off work and that provision had been made for a replacement. We found that although the maintenance person was still not back at work, no replacement had been put in place. We discussed this with the service manager and asked them to review this. We will review this at the next inspection. We appreciate that the home will be moving premises at some point next year and would therefore not expect any unnecessary furnishings and fittings to be replaced, however, we did find some areas that could be easily fixed or replaced in the meantime to ensure a more pleasant place to live for the residents. We will monitor this at our next inspection. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Inspection report continued Davislea Home For The Elderly, page 23 of 34

24 Quality Theme 3: Quality of Staffing Grade awarded for this theme: Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths At this inspection we focused on the areas for development from the previous inspection carried out on 4 September After we reviewed the information we gathered during the inspection process, we decided that the service had continued to perform in this quality statement at a good level. There was an inspection volunteer involved in the inspection. An inspection volunteer is a member of the public who volunteers to work alongside the inspectors. Inspection volunteers have a unique experience of either being a service user themselves or being a carer for someone who has used services. The inspection volunteer role is to speak with people using the service being inspected and gathering their views. The inspection volunteer involved in the inspection talked to residents and their relatives, comments included: "get on well with the staff" "staff are fine" "great carers" "staff are good with us" "they treat us very nice" "staff are very good and helpful" "staff are very good at encouraging you" "staff are approachable." The inspection volunteer's observations were: "I observed staff to be friendly and approachable." See service strength under quality theme 1, statement 1 for more information. Davislea Home For The Elderly, page 24 of 34

25 Areas for improvement See areas for improvement under quality theme 1, statement 1 for more information. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Davislea Home For The Elderly, page 25 of 34

26 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths At this inspection we focused on the areas for development from the previous inspection carried out on 4 September After we reviewed the information we gathered during the inspection process, we decided that the service had performed in this quality statement at a good level. We made a requirement at the previous inspection that the provider must ensure that all new staff have induction training within their three month induction period as described in their own policies and procedures. We looked at records for new staff and found that an induction process had been completed. This requirement had been met. We spoke with staff who told us that they received regular supervision from the senior staff and that this was useful and that they could use this to identify any areas that they wanted more training or support with. We found that staff were polite and respectful when supporting residents and we saw lots of good interaction between staff and residents. Residents and relatives we spoke with were very complimentary about staff. We looked at minutes of meetings and saw that these had taken place for all departments within the home. This gave an opportunity for staff to offer any ideas or suggestions and for information to be shared about the service. At the previous inspection the staff group had been very unsettled and there was a high volume of agency staff being used. We found that this had settled and we found staff to be enthusiastic about their work. Davislea Home For The Elderly, page 26 of 34

27 Areas for improvement Since the previous inspection there had been a period where the manager was absent, followed by two changes of managers. This meant that senior care workers had not received supervision and guidance for periods of time. We were told that since the current manager started at the end of January they had had meetings with him and that supervision sessions were planned. We will monitor progress at the next inspection. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Inspection report continued Davislea Home For The Elderly, page 27 of 34

28 Quality Theme 4: Quality of Management and Leadership Grade awarded for this theme: 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 At this inspection we focused on the areas for development from the previous inspection carried out on 4 September After we reviewed the information we gathered during the inspection process, we decided that the service had continued to perform in this quality statement at a good level. There was an inspection volunteer involved in the inspection. An inspection volunteer is a member of the public who volunteers to work alongside the inspectors. Inspection volunteers have a unique experience of either being a service user themselves or being a carer for someone who has used services. The inspection volunteer role is to speak with people using the service being inspected and gathering their views. The inspection volunteer's observations were: "Residents I spoke to were not sure who the manager was. However, they did say that they would speak to a member of staff if they had any problems or issues. The manager was fairly new." See service strength under quality theme 1, statement 1 for more information. Areas for improvement See areas for improvement under quality theme 1, statement 1 for more information. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Davislea Home For The Elderly, page 28 of 34

29 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 this inspection we focused on the areas for development from the previous inspection carried out on 4 September After we reviewed the information we gathered during the inspection process, we decided that the service had performed in this quality statement at a good level. We repeated a requirement at the previous inspection that the provider must ensure that robust and accountable ways of carrying out regular and adequate monitoring and audit of resident experience and outcomes and staff practice are introduced. We found that medication competencies had recently been completed with staff. We saw that regular meetings had taken place (See quality theme 1, statement 1 and quality theme 3, statement 3 for more detail). We saw that the manager had completed quality audits of the home which looked at various areas including accidents and incidents, resident reviews and medication checks. This requirement had been met. We made a requirement at the previous inspection that the provider must review their current staffing situation in relation to skill mix of permanent and agency staff. Also, that they must introduce a system of ensuring that all agency staff are fully inducted to the service and records kept of this. We found that the number of agency staff used currently was not in such numbers as to still be an area of concern. We spoke with staff who told us that this was now much better. This requirement had been met. We considered the recent absence and subsequent changes of manager and were heartened at the improvements led by the senior care workers. This demonstrated an ambition to improve the service for the residents. Areas for improvement The manager and staff team should now build on current practices and quality assurance methods to assess and improve the service that they provide. This should include working through their devised action plans to meet the remainder of the outstanding requirement and recommendations. Grade awarded for this statement: Number of requirements: 0 Number of recommendations: 0 Davislea Home For The Elderly, page 29 of 34

30 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 None. 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). Davislea Home For The Elderly, page 30 of 34

31 5 Summary of grades Quality of Care and Support - Statement 1 Statement 3 Quality of Environment Adequate Statement 1 Statement Adequate Quality of Staffing - Statement 1 Statement 3 Quality of Management and Leadership - Statement 1 Statement 4 6 Inspection and grading history Date Type Gradings 4 Sep 2014 Unannounced Care and support 3 - Adequate Environment 3 - Adequate Staffing 3 - Adequate Management and Leadership 2 - Weak 11 Mar 2014 Unannounced Care and support 3 - Adequate Environment 3 - Adequate Staffing Management and Leadership 27 Jun 2013 Unannounced Care and support Environment Staffing Management and Leadership Davislea Home For The Elderly, page 31 of 34

32 1 Feb 2013 Unannounced Care and support Environment Staffing 5 - Very Good Management and Leadership 5 - Very Good 27 Jun 2012 Unannounced Care and support 5 - Very Good Environment 5 - Very Good Staffing 5 - Very Good Management and Leadership 5 - Very Good 9 Sep 2011 Unannounced Care and support 3 - Adequate Environment 3 - Adequate Staffing Not Assessed Management and Leadership Not Assessed 7 Oct 2010 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing Management and Leadership Not Assessed 29 Apr 2010 Announced Care and support 5 - Very Good Environment Staffing Not Assessed Management and Leadership Not Assessed 14 Jan 2010 Unannounced Care and support 5 - Very Good Environment Not Assessed Staffing 5 - Very Good Management and Leadership Not Assessed 22 Jul 2009 Announced Care and support Environment Staffing 5 - Very Good Management and Leadership 3 Mar 2009 Unannounced Care and support Environment Staffing Management and Leadership Not Assessed Davislea Home For The Elderly, page 32 of 34

33 31 Aug 2008 Announced Care and support Environment Staffing Management and Leadership All inspections and grades before 1 April 2011 are those reported by the former regulator of care services, the Care Commission. Davislea Home For The Elderly, page 33 of 34

34 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: Davislea Home For The Elderly, page 34 of 34