Lambhill Court Care Home Service Adults 40 Lambhill Street Kinning Park Glasgow G41 1AU Telephone:

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1 Lambhill Court Care Home Service Adults 40 Lambhill Street Kinning Park Glasgow G41 1AU Telephone: Type of inspection: Unannounced Inspection completed on: 25 February 2015

2 Contents Page No Summary 3 1 About the service we inspected 5 2 How we inspected this service 7 3 The inspection 16 4 Other information 32 5 Summary of grades 33 6 Inspection and grading history 33 Service provided by: Lambhill Court Ltd 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 Lambhill Court, page 2 of 36

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 3 Adequate Quality of Environment 3 Adequate Quality of Staffing 3 Adequate Quality of Management and Leadership 3 Adequate What the service does well The staff team were committed to the success of the service, and we saw evidence of a lot of work in progress to make improvements. An Intermediate Care service had been established, and was working well to provide an assessment and rehabilitation service to people recently discharged from hospital. What the service could do better Some service users had limited access to dedicated dining and lounge facilities because of water damage to their care unit. They were using the 'Gym' area which did not provide a positive environment. Some equipment was in a poor state of repair and needed to be replaced. Systems of supporting staff needed further development. Lambhill Court, page 3 of 36

4 What the service has done since the last inspection The service had met most of the requirements and recommendations we had made at our previous inspection. We saw improvements in many aspects of the service including the personal care and presentation of individuals using the service, and the quality of care plans and risk assessments. Conclusion Although we witnessed areas of good practice during the inspection, we identified some areas for improvement. The management team were open and responsive to our observations and understood the areas that needed to improve in order to improve some aspects of the quality of service. Where environmental refurbishment had taken place, this was to a good standard, however further work needed to be undertaken timeously to provide a homely environment for people using the service. Lambhill Court, page 4 of 36

5 1 About the service we inspected The Care Inspectorate regulates care services in Scotland. Information about all care services is available on our website at This service was previously registered with the Care Commission and transferred its registration to the Care Inspectorate on 1 April Requirements and recommendations 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. Recommendations are based on the National Care Standards, relevant codes of practice and recognised good practice. A requirement is a statement which sets out what is required of a care service to comply with the Public Services Reform (Scotland) Act 2010 and Regulations or Orders made under the Act, or a condition of registration. Where there are breaches of Regulations, Orders or conditions, a requirement must be made. Requirements are legally enforceable at the discretion of the Care Inspectorate. Lambhill Court Care Home is owned and managed by Lambhill Court Ltd. The Care Home provides residential and nursing care and support to a maximum of 66 older people. One unit of the care home was closed pending refurbishment and discussion about future use. Should this unit be brought into use the maximum numbers would be higher. The current registration certificate is for 109 places but this was dependent on previous usage of shared rooms and will now be the subject of a variation application to ensure correct numbers are reflected on the registration certificate. Lambhill Court Care Home is a large three storey building, sited close to local amenities and transport links. The Care Home is divided into four separate units, Kelvin, Clyde, Afton Square and McFarlane House. There were 52 service users at the time of this inspection. McFarlane unit was closed, however three service users were living there. Ninetythree of the 109 places are single rooms with en-suite bathroom facilities. Some of the en-suite bathrooms had baths that were inaccessible to older people. Lambhill Court, page 5 of 36

6 The units all had communal lounge and dining rooms. There were communal bathrooms with adapted baths and wet floor shower areas. Access to outdoor space was limited to those who were more able. Lambhill Court Care Home aims to enhance the quality of life of its residents. Based on the findings of this inspection this service has been awarded the following grades: Quality of Care and Support - Grade 3 - Adequate Quality of Environment - Grade 3 - Adequate Quality of Staffing - Grade 3 - Adequate Quality of Management and Leadership - Grade 3 - Adequate Inspection report continued This report and grades represent our assessment of the quality of the areas of performance which were examined during this inspection. Grades for this care service may change following other regulatory activity. You can find the most up-to-date grades for this service by visiting our website or by calling us on or visiting one of our offices. Lambhill Court, page 6 of 36

7 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 This unannounced inspection was undertaken by two inspectors during the day time on 24 and 25 February The inspection commenced at 9am and concluded at 4pm. The outcome of the inspection was discussed with the manager and senior managers at the end of the inspection. Positive discussion took place around the inspection findings and how to improve the quality of the service. As requested by us, the service sent us an annual return and a self assessment: this useful information was used to help us plan our inspection. We also looked at information such as notifications which the service had sent to us. In addition, we gathered evidence from various sources, including the relevant sections of policies and procedures, records and other documents including: - Care plans - Risk assessments - Staff training records and training plan - Complaints investigations - Accident and incident records - Minutes of meetings with service users and carers - Reports from other care professionals - Survey questionnaires - Supervision records - The service's audit information. - Discussion with the visiting G.P. We talked with some of the staff on duty and observed staff providing care during the two days of our visit. We also talked with six service users and two carers that we met with. Lambhill Court, page 7 of 36

8 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 report continued 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 Lambhill Court, page 8 of 36

9 What the service has done to meet any requirements we made at our last inspection The requirement The service provider must ensure that individual assessment, planning and delivery of meaningful activities takes place for all residents. This is in order to comply with SSI 210/ 2011, Welfare of users Regulation 4 (1)A provider must: (a)make proper provision for the health, welfare and safety of service users; Timescale: 3 months. What the service did to meet the requirement Please refer to comments in Quality Theme 1, Statement 3 We recognise that work was progressing in this respect. The requirement is: Met - Within Timescales The requirement The service provider must ensure that smoking risk assessments have been carried out for any resident who may consider smoking in their bedroom. This is not a designated smoking area and there must be adherence to the smoking legislation. This is in order to comply with: SSI 210/2011 Welfare of users, Regulation 4 (1)A provider must: (a)make proper provision for the health, welfare and safety of service users. Timescale: one month. Advice should be sought from Business Regulation Environment and Sustainability Land and Environmental Services. Phone: healthandsafety@glasgow.gov.uk Lambhill Court, page 9 of 36

10 The Prohibition of Smoking in Certain Premises (Scotland) Regulations 2006 Smoking, Health and Social Care (Scotland) Act What the service did to meet the requirement Please refer to comments in Quality Theme 2, statement 2. The requirement is: Met - Within Timescales Inspection report continued The requirement The service provider must ensure that care plans record all the health and welfare needs of service users to inform of how those needs are to be met. There should be specific reference to the following: - Accurate recording of the details of care interventions - Risk assessments must reflect all identified risks - Records must be regularly updated to reflect change - Consistency in the use of risk assessment and dependency assessment tools This is in order to comply with: SSI 2011/ 210 Welfare of users Regulation 4 (1)A provider must: (a)make proper provision for the health, welfare and safety of service users. Timescale: four months from receipt of this report. What the service did to meet the requirement Please refer to comments in Quality Theme 1, Statement 1 and Quality Theme 1, Statement 3. The requirement is: Met - Within Timescales The requirement The service provider must ensure that service users' dignity and choice are respected. In order to do this the provider must ensure that individual needs and preferences for personal care are met. This is in order to comply with: SSI 2011/ 210 Principles Regulation 3 Lambhill Court, page 10 of 36

11 A provider of a care service shall provide the service in a manner which promotes quality and safety and respects the independence of service users, and affords them choice in the way in which the service is provided to them. Welfare of users Regulation 4 (1)A provider must: (a)make proper provision for the health, welfare and safety of service users; (b)provide services in a manner which respects the privacy and dignity of service users. Timescale: 1 month from receipt of this report. What the service did to meet the requirement Please refer to comments in Quality Theme 1, Statement 3 and Quality Theme 4, Statement 4. The requirement is: Met - Within Timescales Inspection report continued The requirement The service provider must make proper provision for service users oral care including referral to dental services where appropriate. Welfare of users Regulation 4 (1) A provider must: (a) make proper provision for the health, welfare and safety of service users; (b) provide services in a manner which respects the privacy and dignity of service users. Timescale: 1 month from receipt of this report. What the service did to meet the requirement Please refer to comments in statement 1.3 The requirement is: Met - Within Timescales The requirement The service provider must devise and implement a system to ensure that the expected standard of cleanliness is maintained within the service at all times. Lambhill Court, page 11 of 36

12 This must ensure: - All areas of the care home are kept clean and free of odours - There are detailed cleaning schedules for all areas of the care home - There is effective monitoring of the cleanliness of the premises on a sufficiently frequent basis to ensure the expected standard is being achieved This is in order to comply with: SSI 2011/ 210 Welfare of users Regulation 4 (1) A provider must: (a) make proper provision for the health, welfare and safety of service users. SSI 2011/210 Fitness of premises Regulation 10 (2) Premises are not fit to be used for the provision of a care service unless they: (a) are suitable for the purpose of achieving the aims and objectives of the care service which are set out in the statement of aims and objectives; (b) are of sound construction and kept in a good state of repair externally and internally. Timescale: one month from receipt of this report. What the service did to meet the requirement Please refer to comments in Quality Theme 2, Statement 2. The requirement is: Met - Within Timescales The requirement The service provider must compile and undertake a development and on-going refurbishment plan for upgrading the environment of the care home. This must include: - An on-going redecoration plan for the remainder of the bedrooms and communal areas - The replacement of distressed fabric and furnishings Lambhill Court, page 12 of 36

13 - The provision of an environment appropriate to the needs of service users with memory problems. This is in order to comply with: SSI 210/2011 Regulation 10 Inspection report continued (2) Premises are not fit to be used for the provision of a care service unless they: (a)are suitable for the purpose of achieving the aims and objectives of the care service which are set out in the statement of aims and objectives; (b)are of sound construction and kept in a good state of repair externally and internally; Timescale: four months from receipt of this report. What the service did to meet the requirement Action taken: Please refer to comments in Quality Theme 2, Statement 2. The requirement is: Not Met The requirement The service provider must take steps to ensure that all staff working in the service receive appropriate training which will equip them with the skills and competencies required to meet the care and welfare needs of all of the service users. The provider must ensure that newly recruited staff are given a comprehensive induction and are supported by appropriate and experienced staff until they are deemed competent. This is in order to comply with: SSI 2011/210: Regulation 13 - Staffing Timescale -within four months of receipt of this report. What the service did to meet the requirement Please refer to comments in Quality Theme 3, Statement 3. The requirement is: Not Met The requirement The provider must make significant improvements to quality assurance processes to ensure systems are robust to identify areas of poor practice and are responsive to improving the home's performance. The systems must be focused on improved Lambhill Court, page 13 of 36

14 outcomes for service users: and must include the involvement of all key stakeholders including staff. This is in order to comply with SSI 2011/ 210: Regulation (4) (a) (b), Welfare of users and Regulation 3 - Principles. Timescale: within 4 months of receipt of this report. What the service did to meet the requirement Please refer to comments in Quality Theme 4, Statement 4. The requirement is: Not Met Inspection report continued 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 service submitted a self assessment as requested by us earlier in the year. Taking the views of people using the care service into account We talked with six residents during our visit. Here are some comments: 'I'm back on my feet since coming here and looking forward to getting home'. 'My new room is lovely, just like a hotel'. 'Sometimes its cold in here'. 'I get bored during the day'. 'The staff are all nice, they are kept going'. 'The food is very good, plenty of choice, I've put on weight'. Lambhill Court, page 14 of 36

15 Taking carers' views into account We talked with two carers during our visit. Here are some comments: 'The home is getting better'. 'I've never had any problems here'. 'I think the care is good, Mum keeps well'. 'There could be more for people to do'. Lambhill Court, page 15 of 36

16 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: 3 - Adequate 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 We found that the service was performing at an adequate level in the areas covered by this statement. We concluded this after we: - Talked with the service manager, care staff, residents and visitors - Looked at information in residents' personal plans - Looked at the minutes of residents' and carers' meetings - Looked at notice boards - Looked at documentation about events that had taken place within the service - Observed staff working with the residents. There was some evidence that residents and carers views had been sought about some aspects of the service including choice of décor and furnishings, menu planning and activities. A key worker system had been introduced which identified a dedicated member of staff as a point of contact for residents and their carers. Methods of gathering feedback included suggestion boxes, questionnaires and meetings. Lambhill Court, page 16 of 36

17 Some recent actions taken as a result of feedback were a new optician for the care home, and using to communicate with carers. The outcomes of feedback were displayed on notice boards in the home. We sampled some care plans, and we could see a person centred approach was being taken by staff. This helped to ensure that residents and carers preferences and aspirations were considered when planning their care and support. Residents and their carers had been involved in this activity. A brochure about the home was available for people when they were considering using the service: this contained detailed information about all aspects of moving in and living in the care home. Information on available advocacy services was on display. An advocacy service is an independent service which supports individuals to raise any issues that are important to them. There was evidence of Adults with Incapacity Certificates and where there was guardianship a copy of the order was present. This was good practice as it indicated clearly to staff who had been given powers to make decisions for a resident who could not do this for themselves. The manager had put in place a system to ensure that the required six monthly care reviews would be undertaken, and we noted that most of the reviews were scheduled to take place. We looked at a sample of minutes of reviews recently undertaken, and these some of these evidenced the involvement of residents and carers. Areas for improvement Some residents, with memory problems, had limited ability to give feedback without considerable support, and we were unable to see how staff were able to consistently provide this support. We think that more development is needed in this area to ensure staff are trained and competent in being able to support residents with dementia to give views. Some review minutes lacked detail, and it was difficult to determine the outcomes agreed to be taken forward. There was an ' Its My Day' activity whereby service users should be involved in a personal review of their care plan, but the effectiveness of this was not clear in all cases. There was an inconsistent approach to documenting the agreed outcomes of review meetings. (See recommendation 1). Lambhill Court, page 17 of 36

18 Overall, there could be much more evidence of proactive approaches to gaining feedback from residents and relatives on all four of the quality themes. The service should work to improve this. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 1 Recommendations 1. The service provider should ensure that there is a good level of detail recorded within the formal review process, that explains service users and relatives views about their care. National Care Standards, Care Home for Older People, Standard 6, Support Arrangements Lambhill Court, page 18 of 36

19 Statement 3 We ensure that service users' health and wellbeing needs are met. Service strengths The home had an adequate performance in relation to this statement. We gathered evidence through: - Sampling records - Sampling care plan information - Observing practice and speaking to staff, service users and relatives. Residents we met with looked well, and there was better attention to individuals personal appearance. We observed staff delivering personal care ensuring the residents' dignity was preserved, for example when assisting to the toilet. Clothing was appropriate, clean and ironed. We noted that soiled items of clothing were replaced promptly. We saw staff asking residents if they were happy with their choice of clothing and hairstyle: this ensured that individuals were comfortable with their appearance. The service had a strong focus on ensuring service users were being given nutritious meals and snacks, and we were pleased to note that most people were maintaining their weight. The catering staff were working closely with the care staff to ensure the correct diets were being provided. This included fortified foods and high calorie items. Snacks and drinks were available throughout the day and night, and we observed staff offering these regularly during our visit. Service users told us the quality of food was very good, and there was plenty of choice. Special diets were well presented and appetising. There were systems in place to monitor weight loss. A management overview ensured appropriate action was being taken, for example referral to other members of the health team, and provision of an appropriate diet. There was a good supply of pressure relieving equipment to support residents at risk of pressure ulcers whilst seated or whilst in bed: this reduced the likelihood of developing skin problems. Very few residents had skin problems. Lambhill Court, page 19 of 36

20 The staff had introduced the best practice guidance 'Caring for Smiles': this ensured residents were given support to care for their mouth and teeth. This is important as it helps to ensure individuals are able to eat, and also helps to reduce the opportunity for infections. All residents had access to a dentist for assessment and treatment. We checked progress in relation to the management and prevention of falls. We were pleased to see that the incidence of falls was continuing to reduce. The service manager was monitoring this closely. The quality of the care plans had improved. Those we sampled contained assessments and care plans relevant to actual care needs, and there was evidence these were being reviewed and updated as care needs changed. We recognise this work is on-going, and were pleased with the progress being made. Accidents and incidents were being dealt with properly by the service, and there was some evidence of a 'lessons learned' approach by management. Additional support measures were put in place when particular risks were identified: this helped to keep people safe. Some more able service users told us they enjoyed the activities they could attend including arts and crafts, sing songs and games. Areas for improvement We had some concerns about the quality of experience of people residing in Afton unit. Due to damage to the building in recent bad weather, they were unable to use their dedicated lounges and dining room. As a contingency until the required repairs were undertaken, an alternative was to use the 'Gym' area as a dining/lounge area. This area did not provide a comfortable or homely environment. It was very noisy, felt cold at times, and was used a thoroughfare by work men and staff. There was no area for residents who may have preferred a smaller quieter area to spend their time. There was limited opportunity for residents and their visitors to access a private area other than the bedrooms which were some distance away. Because of the distance between the 'Gym' and residents bed rooms, it was very difficult for those who needed assistance to move freely around the home. Staff were challenged during meal times to provide the service and support residents in both the 'Gym' area and the bedrooms. As a result, the meal times were protracted, and residents had to wait lengthy periods between meals or for assistance. We were concerned that the area being used for food preparation and meals service did not have hand washing facilities. This increased the risk of the spread of infection. Lambhill Court, page 20 of 36

21 Whilst we recognise this is a contingency, we have repeated the requirement made at our previous inspection about environmental improvements. (See requirement 1) Whilst the manager had introduced a 'whole home' approach to the provision of meaningful activities, we saw limited evidence that this was being effective, particularly for those in Afton Unit. This has an adverse effect on well-being, and can increase feelings of boredom, isolation and self-worth. We recognised that work was progressing in this respect: the manager was committed to ensuring all residents had opportunity to do things that were of interest to spend their day. Staff had been working with residents and their families to find out what was of interest to them. We will assess progress at our next inspection. Grade awarded for this statement: 3 - Adequate Number of requirements: 1 Number of recommendations: 0 Requirements 1. The service provider must compile and undertake a development and ongoing refurbishment plan for upgrading the environment of the care home. This must include: - An ongoing redecoration plan for the remainder of the bedrooms and communal areas - The replacement of distressed fabric and furnishings - The provision of an environment appropriate to the needs of all service users including those with memory problems - A timescale for completion. This is in order to comply with: SSI 210/2011 Regulation 10 (2)Premises are not fit to be used for the provision of a care service unless they: (a)are suitable for the purpose of achieving the aims and objectives of the care service which are set out in the statement of aims and objectives; (b)are of sound construction and kept in a good state of repair externally and internally; Lambhill Court, page 21 of 36

22 Timescale: To start immediately and be completed within six months of receipt of this report. Lambhill Court, page 22 of 36

23 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 We found that the service was performing at an adequate level in the areas covered by this statement. We came to this conclusion because residents and relatives had some opportunities to provide feedback on the environment. However, feedback was limited to those who were most able. There were plans to undertake further refurbishments within the home and the manager intended to consult with service users and carers in this respect. There had already been agreement to develop the conservatory into an activities area and install sensory features in the garden grounds. Service users we talked with told us they were happy with the standard of the work that had been carried out so far, particularly to their bedrooms. Areas for improvement The comments made in Quality Theme 1, Statement 1 and Quality Theme 1, Statement 3 are also applicable to this statement. Further re-decoration and refurbishment was needed within all areas of the home to provide a more homely environment. Features to assist the orientation of those with memory problems would be of benefit, particularly improved signage and lighting. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Lambhill Court, page 23 of 36

24 Statement 2 We make sure that the environment is safe and service users are protected. Service strengths The home had an adequate performance in relation to this statement. We gathered evidence through: - Sampling records - Sampling care plan information - Looking at the environment, including bedrooms, communal lounges, dining rooms and bathroom facilities - Observing practice and speaking to staff, service users and relatives. We found people received care, treatment and support in a generally clean environment: the standard of cleanliness had improved since our previous inspection. There were measures in place to minimise the risk of infection: there was a good supply of equipment for staff to use, and we saw this being used correctly. We saw schedules in place for daily, weekly and monthly infection control tasks carried out in bedrooms, lounge and dining areas, corridors, laundry and the kitchen. We spoke with the housekeepers who confirmed the tasks they carried out. We inspected a cleaning cupboard where we saw securely stored equipment and materials. Cleaning equipment was colour coded and designated for use only in specified areas in accordance with relevant guidance. All these measures demonstrated the provider was taking adequate steps to reduce the risk and spread of infection. Regular servicing and maintenance checks were carried out to make sure equipment and essential services functioned properly, such as heating, electrics and water supply. There were also regular fire checks, including weekly testing of the fire alarm system. We saw a log was kept of all maintenance tasks identified and these had been marked as completed when the task had been actioned. This showed the provider was taking steps to keep the building safe and maintained. There was provision of a designated area to ensure those residents who chose to smoke could do so safely. Lambhill Court, page 24 of 36

25 Most of the communal areas, for example the lounges were spacious and uncluttered: this was good practice in minimising the risk of people tripping or falling. Areas for improvement At our previous inspection, we had identified that some essential care equipment was in poor condition and needed to be replaced. We noted that this remained outstanding. Some toilet frames were rusted, and shower curtains in poor condition. We were advised these would be replaced as part of the refurbishment programme. Several of the en suite toilets were inaccessible due to being used as storage for wheelchairs and other equipment. There were instances of communal areas being left unattended by staff, and residents having no access to a call bell to summon assistance. This was addressed when identified to the service manager, who had started to review the deployment of staff. The windows throughout the home needed cleaning. We have made comments in Quality Theme 1, Statement 3 about the suitability of the Afton environment for some residents. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Lambhill Court, page 25 of 36

26 Quality Theme 3: Quality of Staffing Grade awarded for this theme: 3 - Adequate Statement 1 We ensure that service users and carers participate in assessing and improving the quality of staffing in the service. Service Strengths The performance in relation to this standard statement was adequate. We came to this conclusion because there was some evidence of service user and relatives involvement. Overall, opportunities to give comments were limited to those who were most able. Most residents needed some support in order to be able to express views. The comments and recommendations made in Quality Theme 1, Statement 1 are also applicable to this statement. Service users, carers and visiting health professionals we talked with during our visit were complimentary about the quality of the staff. They told us they were kind and helpful and made them feel welcome. Areas for improvement The comments made in Quality Theme 1, Statement 1 are also applicable to this statement. The 'keyworker' system had been introduced, however the deployment of staff between the care units may have an impact on its effectiveness. We discussed this with the management team during our feedback, and it will be given further consideration. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Lambhill Court, page 26 of 36

27 Statement 3 We have a professional, trained and motivated workforce which operates to National Care Standards, legislation and best practice. Service strengths The home had an adequate performance in relation to this statement. We gathered evidence through: - Sampling records - Observing practice and speaking to staff, residents and relatives. Most of the staff we met with were committed and wanted the home to be a success. They told us they were happy working at Lambhill Court. We saw evidence of empathetic, warm caring and positive engagement from the staff. There was evidence of service users having been referred to nursing and other Allied Healthcare professionals in the community for further advice such as the District Nurse, Dietician and Occupational Therapist. This advice had been followed with positive effect, for example in managing falls risk. The manager had undertaken a training needs analysis to identify and prioritise a staff training plan. This was work in progress. There was evidence that some staff had undertaken training in the past year including Moving and Assisting, Medication, Oral health care. Infection Control, care Planning. Falls Risk management. Care staff had opportunities to work towards a recognised care qualification. Some of the nursing staff had been trained in enhanced skills, for example phlebotomy and verification of death. There were 'Champions' for some key care areas: these staff provided enhanced care and clinical advice to the care team. There was a programme to develop the leadership skills of senior staff : staff we talked to told us this was of benefit. Lambhill Court, page 27 of 36

28 We sampled some recruitment files and noted an improvement in the services' recruitment practice. This helped to ensure that staff were being recruited safely. Newly recruited staff were given an induction programme to ensure they could carry out their work competently. All care staff were registered or had applied for registration with the SSSC, the authority which regulates care workers: this helps to protect vulnerable adults and ensures staff are appropriate to work in the sector. Regular staff meetings had been taking place to ensure staff were kept up to date with service issues and developments. They also provided staff with opportunity to contribute, and have their views about the service heard. The staffing structure was being reviewed to provide clearer lines of responsibility and accountability: this would be of benefit. Staff we talked with told us they felt there was a better sense of direction in the service, communication had improved and that they felt they were being listened to and supported by the management team. Areas for improvement The service should continue with the work already established in this area in terms of providing staff with training relevant to their job and to meet the care needs of the residents. We identified that one staff member had not undertaken mandatory training essential for his job. There had been an inconsistent approach to providing staff with regular supervision sessions. Supervision is an important aspect of supporting and developing staff to ensure they are practicing safely and to a good standard. The service manager was responsive to our concerns in this respect, and had formulated a plan to address this issue. We will look at progress at our next visit. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Inspection report continued Lambhill Court, page 28 of 36

29 Quality Theme 4: Quality of Management and Leadership 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 management and leadership of the service. Service strengths The home had an adequate performance in relation to this statement. We gathered evidence through: - Sampling records - Observing practice and speaking to staff, residents and relatives. The comments and recommendation made in Quality Statement 1, Theme 1 are also applicable to this statement. It was evident during our visit that the manager was well known to the people using the service and their visitors, and maintained a high profile within the care units. This meant people could access her easily, and made for good open lines of communication. Areas for improvement The comments and recommendation made in Quality theme 1, statement 1 are also applicable to this statement. Service users and relatives had not yet had the opportunity to view and comment on the service's own self assessment against the quality themes and standards. The openness to share this information and seek comments to take into account would be good practice. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Lambhill Court, page 29 of 36

30 Statement 4 We use quality assurance systems and processes which involve service users, carers, staff and stakeholders to assess the quality of service we provide. Service strengths The home had an adequate performance in relation to this statement. We gathered evidence through: - Sampling records - Observing practice and speaking to staff, residents and relatives. During our visit, it was evident that the service manager knew what was happening in the home on a day to day basis. There were daily 'flash' meetings each morning with all key staff: this ensured each department knew about significant events happening that day. This exchange of information helped to assure an effective service, responsive the needs of the residents, and contributed to improved team working. A Quality Assurance system was being developed, and some audits were undertaken regularly to monitor the standard of the service. This included the standard of cleanliness, quality of care plans and risk assessments, medicines management, and aspects of clinical practice such as falls risk. A summary of all the audits carried out was reviewed by senior management. We saw the effectiveness of these systems in some improved care outcomes for people using the service, for example, better attention to personal care and appearance, and better staff engagement with the residents. Assessments of need were being reviewed every month to ensure that the numbers of staff on shift were sufficient to meet residents' care and welfare needs. An accident reporting and recording procedure and system was in place for recording and monitoring accidents/incidents. Any significant or critical incidents/accidents were reported to senior managers, other professional bodies and the Care Inspectorate as required. The manager was aware of the responsibilities around notifications to the Scottish Social Service Council (SSSC), including the reporting of staff dismissal (or consideration of staff dismissal) on the grounds of misconduct. Lambhill Court, page 30 of 36

31 Likewise, the service's responsibility to notify the Care Inspectorate of matters of misconduct including theft was understood. We recognise that work continues to progress in this area. Areas for improvement The service should consider how it could better involve all key stakeholders in the development and monitoring of a service improvement plan, and how it could better evidence improved care outcomes for people using the service. The manager recognised that these areas needed to be further developed, particularly in relation to involving the staff and other key people such as visiting care professionals. The Deputy manager position remained vacant and needed to be recruited. This would provide valuable support to the service manager. Grade awarded for this statement: 3 - Adequate Number of requirements: 0 Number of recommendations: 0 Lambhill Court, page 31 of 36

32 4 Other information Complaints We were investigating two complaints at the time of our visit. The investigations were on going. 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). Lambhill Court, page 32 of 36

33 5 Summary of grades Quality of Care and Support Adequate Statement 1 Statement Adequate 3 - Adequate Quality of Environment Adequate Statement 1 Statement Adequate 3 - Adequate Quality of Staffing Adequate Statement 1 Statement Adequate 3 - Adequate Quality of Management and Leadership Adequate Statement 1 Statement Adequate 3 - Adequate 6 Inspection and grading history Date Type Gradings 28 Aug 2014 Unannounced Care and support 2 - Weak Environment 2 - Weak Staffing 3 - Adequate Management and Leadership 2 - Weak 8 Jan 2014 Unannounced Care and support 3 - Adequate Environment 3 - Adequate Staffing 3 - Adequate Management and Leadership 3 - Adequate 14 Jun 2013 Unannounced Care and support 2 - Weak Environment 3 - Adequate Staffing 3 - Adequate Management and Leadership 3 - Adequate Lambhill Court, page 33 of 36

34 25 Jan 2013 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 3 - Adequate 7 Mar 2012 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 20 Apr 2011 Unannounced Care and support 5 - Very Good Environment 4 - Good Staffing 4 - Good Management and Leadership 4 - Good 19 Dec 2010 Unannounced Care and support 4 - Good Environment Not Assessed Staffing 4 - Good Management and Leadership Not Assessed 26 Apr 2010 Announced Care and support 5 - Very Good Environment 4 - Good Staffing Not Assessed Management and Leadership 4 - Good 5 Nov 2009 Announced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership 3 - Adequate 27 May 2009 Unannounced Care and support 4 - Good Environment 4 - Good Staffing 4 - Good Management and Leadership Not Assessed 17 Dec 2008 Unannounced Care and support 3 - Adequate Environment 4 - Good Staffing 4 - Good Management and Leadership Not Assessed Lambhill Court, page 34 of 36

35 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. Lambhill Court, page 35 of 36

36 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: Lambhill Court, page 36 of 36